Traveler's Diarrhea PDF

Food and Water : Travelers Diarrhea and Beyond Mary-Louise Scully M.D. Travel and Tropical Medicine Center Sansum Clinic Santa Barbara, CA USA Disclosures ML Scully - None Traveler’s Diarrhea “COOK IT, PEEL IT, BOIL IT, OR FORGET IT ! ” Easy to say, hard to follow Travelers’ Diarrhea Etiology...

Food and Water : Travelers Diarrhea and Beyond Mary-Louise Scully M.D. Travel and Tropical Medicine Center Sansum Clinic Santa Barbara, CA USA Disclosures ML Scully - None Traveler’s Diarrhea “COOK IT, PEEL IT, BOIL IT, OR FORGET IT ! ” Easy to say, hard to follow Travelers’ Diarrhea Etiology • Bacterial agents: 80-90% – Enterotoxigenic E. coli (ETEC), Campylobacter, Salmonella, Shigella, Enteroaggregative E.coli, Aeromonas, Pleisiomonas, etc • Viral agents: 5–15 % – Noroviruses, rotavirus, astrovirus, sapovirus • Parasitic agents: 10 % – Giardia, Cryptosporidium, Cyclospora, Entamoeba histolytica, Cystoisospora belli (Isospora belli) Travelers Diarrhea • 1970 ‘s – 1985 - prophylaxis standard ( Bactrim, doxycycline ) • 1985 – NIH Consensus Conference - no prophylaxis routinely • 1990 – 2000 ‘s – “Golden Age” of TD self treatment – Quinolones, macrolides, rifamycins • The “new” approach in 2018 Expert Panel convened to establish new guidelines Published in JTM in 2017 Travelers Diarrhea • Clinical syndrome that results from microbial contamination of ingested food and water • Traditional definition of 3 or more unformed stools in a 24 hour period with one or more additional symptoms – Needed for studies on TD – Didn’t capture functional nuances New definitions of Travelers Diarrhea Severity Scale •Mild - diarrhea that is tolerable, is not distressing, and does not interfere with planned activities •Moderate – diarrhea that is distressing and does interfere with planned activities •Severe – diarrhea that is incapacitating or completely prevents planned activities; all dysentery is considered severe. Importance of Gut Microbiome Pub med publications “probiotics” and “health or disease” 430 Finns, screened before and after 11 % Travel alone 21% Travel + diarrhea, no abx 37% Travel + diarrhea, + abx Higher risk south asia travel 23%, TD + D 47%, TD, D, + abx 80% Prospective 1,847 Dutch travelers and 215 non travel household • 34% travelers acquired ESBL • highest risk South Asia • 11 % colonized at 12 months • 12 % probability of onward transmission within household Travelers Diarrhea - Mild Antibiotics – NO Loperamide or BSS - YES Travelers Diarrhea - Moderate Loperamide - yes Antibiotics “may” be considered Azithromycin 1st choice Quinolone – effect on microbiome, C difficile, and musculoskeletal issues Another reason not to use Quinolones .... Travelers Diarrhea - Severe Antibiotics – YES Azithro – preferred Single dose preferred Antibiotic Treatment Recommendations Travelers’ Diarrhea: Non-Antibiotic • Oral rehydration solutions • Bismuth-subsalicylate compounds – 2 tabs (2 oz) QID as prevention ( black tongue / stools) – Not for children < 12, renal insufficiency, gout • Antimotility / antisecretory agents – Loperamide – not absorbed so less CNS (not in ages < 6 years) 12 RCT’s - Only Sacharomyces boulardii CNCM 1-745 found to be effective “Supplements” – not regulated by FDA ? Galacto-oligosaccharides ( B-GOS) ? Bovine collostrum Travelers’ Diarrhea Prevention Simple Hygiene Frequent hand washing w soap and water If no access to clean water 60% alcohol hand sanitizer - not effective for norovirus cryptosporidium and heavily soiled hands Travelers’ Diarrhea Prevention Food and Water Precautions Boiled, filtered, bottled water – safer Hot, cooked foods as opposed to salads / raw food Peeled fruit ( banana, oranges) Bottled soda and beer  Avoid tap water, ice in drinks / smoothies Avoid food from street vendors  Avoid unpasteurized milk Water Treatment 36 year old male traveled to Indonesia 2 week surfing trip. Day 5 - awakens with nausea and vomiting and vomits for about 3 hours. Next day tired but otherwise well and feels well the remainder of his trip. Returns home, and about 12 days after return, develops some malaise, anorexia, belching and burping and eventually some loose stools. Which of the following are more likely to be the cause of his present symptoms ? a. Enterotoxigenic E coli b. Shigella sonnei c. Giardia d. Norovirus Giardisis – Giardia intestinalis Fecal- oral transmission Worldwide Incubation – 1-2 weeks, gradual onset Symptoms – •diarrhea ( foul smelling, greasy stools) •Abd cramps, bloating, flatulence,“sulfa burps” •Anorexia, fatigue, weight loss Treatment – Nitazoxanide, metronidazole, albendazole, paromomycin. Relapse - tinidazole + quinacrine Can detect coinfection Nucleic acid testing does not distinguish viable from non-viable organisms Avoids antibiotics if viral pathogen detected But need to interpret with the clinical presentation Methods for detection of Enteric pathogens Traditional methods • Stool culture • Microscopy – O & P • Antigen detection – Giardia / cryptosporidium New Diagnostics • Multiplex nucleic acid based / PCR • Identifies nucleic acids form multiple bacteria, viral, and parasites • One sample, no refridgeration Clinical Syndromes of Travelers Diarrhea Bacterial pre-formed toxins •symptoms w/i a few hours ( 30 min to 8 hrs ) •Staph, Bacillus cereus, C perfringins Norovirus / Sapovirus •N, vomiting, and diarrhea (6-72 hrs) Bacterial diarrhea •Sudden onset of relatively uncomfortable diarrhea •Incubation ≈ 6-72 hours Parasitic Diarrhea •Incubation often at least 7-10 days •* exception might be Cyclospora in high risk area like Nepal (pre-monsoon) Travelers’ Diarrhea Summary • mild, moderate, severe distinctions to limit use of antibiotics •downstream affect of abx on microbiome, ESBL carriage • Azithro – first line, avoid quinolones (C diff, tendonopathy, anneurysm) •Individualize decision - Access to care – remote traveler vs cruise ship Water Exposure Quiz Survives chlorinated pool water Skin rash after swimming in Lake Victoria Bullous cellulitis and soft tissue necrosis after sea water exposure Rash after “hot tub” Encephalitis after swimming in stagnant fresh water Vibrio vulnificus Mycobacterium marinum Schistosoma mansoni Pseudomonas spp Leptospirosis Naeglera fowlera Cryptosporidium Water Exposure Quiz Vibrio vulnificus •gram negative bacteria •bullous cellulitis after salt water exposure •Risks – alcoholics, cirrhosis water exposure Treatment - IV Ceftriaxone + Doxy Leptospirosis Caused by spirochetes in the genus Leptospira Contact with urine of infected animals – rodents, dogs, cattle, horses, pigs, wild animals; or contaminated water Via skin, mucous membranes, ( eyes, nose, mouth ) Incubation usually ≈ 10 days after exposure (range 2-26 days) Leptospirosis PLOS http://doi.org/10.1371journal.pntd.0004122 Worldwide distribution - > 1 million cases annually Highest morbidity – South and South East Asia, Oceania, the Caribbean, parts of sub-Saharan Africa and Latin America Outbreaks after heavy rains, flooding, recreational activities Abrupt onset of fever, HA, myalgias (calves, lower back), conjunctival suffusion, conjunctival hemorrhage (us. no rash ) Biphasic – acute bacteremic followed by “immune phase” merge in more severe illness Aseptic meningitis, Jaundice, renal failure, pulm hemorrhage, ARDS, myocarditis, rhabdomyolysis. Labs  Bili >  AST/ALT Diagnosis – serology ( can be negative early), PCR if available, culture insensitive. Leptospirosis Treatment – Doxycycline, IV PCN or IV Ceftriaxone Prevention – No vaccine. Cover abrasions, cuts. Protective clothing or gear. Doxycycline 200 mg weekly if high risk exposure unavoidable Water Exposure Quiz Eosinophilic meningitis after travel to Hawaii Deli meat / unpasteurized cheese risk in pregnancy Raw meat and cat litter box risk in pregnancy Toxoplasmosis Mycobacterium marinum Listeria monocytongenes Vibrio cholera Salmonella typhi Rice water stools Eco-chalenge sport events Leptospirosis Angiostrongylous cantonensis Rat lungworm Angiostrongylus cantonenisis Rat lungworm disease Incubation – 1-3 weeks Symptoms – presents like a bacterial meningitis – HA, stiff neck, nausea, vomiting Dx – CSF ++ eosinophils ( but can be absent in early disease Rx – supportive, ?steroids, repeat LP’s if CSF pressure high. Little data to support albendazole Rat lung worm Hawaii Listeria Monocytogenes Gram positive non spore forming rod Can survive / multiply despite refrigeration Severe illness – Sepsis, meningitis Treatment – high dose IV ampicillin (+/- gentamycin) Congenital Toxoplasmosis Cholera • Vibrio cholera – O-group 1 or – O-group 139 • Transmission: water or food contamination • Lack of safe potable water, loss of infrastucture, war, natural diasters https://www.who.int/gho/epidemic_diseases/cholera/en/ Cholera Incubation – 2-5 days • Acute watery diarrhea (rice water stools) • Vomiting, muscle cramps, electrolyte imbalance • Dehydration and Shock Treatment • Rehydration is essential (oral or IV) • Antibiotics ( Doxy or azithro) – reduce fluid requirements and duration of illness Cholera Treatment Rehydration essential ! Antibiotics – Doxy 300 mg x 1, Azithro 1 gram x 1 Cholera vaccines • Dukoral – Oral inactivated whole-cell B subunit (WC/rBS – Cholera and Enterotoxigenic E coli (ETEC) – 2 doses – Duration - ETEC for 3 mo, Cholera 6 mo – 2 years • Shanchol ( oral inactivated bivalent whole cell) – No cholera toxin B subunit; 2 doses 1-2 weeks apart – Protective efficacy 65-67% protection for 2-5 years • Vaxchora - Oral, live attenuated – U.S. as of 2016 - travelers ages 18-64. – Aid and refugee workers - risk of cholera very low in average traveler) CVD 103-HgR Oral Live attenuated (Vaxchora) FDA approved > 18 – 64 years Going to an area of active cholera transmission CDC – “Not for most travelers as most do not visit these areas” VE – 90% at 10 days, 80% at 3 months CVD 103-HgR Oral Live attenuated (Vaxchora) No longer available  No food 60’ before and after No antibiotics in previous 14 days No chloroquine for 10 days after Vaxchora ( decreased efficacy). Malarone OK Prepare and administer in health facility with medical waste disposal Shedding in stool x 7 days, care in immunocompromised close contacts Thank you ! Travel Websites www.cdc.gov/travel CDC Yellow Book www.who.int/ith/en World Health Organization www.immunize.org www.travel.state.gov