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Traveler’s Diarrhea Nicholas Seeliger, M.D.. Traveler’s Diarrhea  diarrheal syndrome which may be caused by a variety of intestinal pathogens contracted.

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Presentation on theme: "Traveler’s Diarrhea Nicholas Seeliger, M.D.. Traveler’s Diarrhea  diarrheal syndrome which may be caused by a variety of intestinal pathogens contracted."— Presentation transcript:

1 Traveler’s Diarrhea Nicholas Seeliger, M.D.

2 Traveler’s Diarrhea  diarrheal syndrome which may be caused by a variety of intestinal pathogens contracted while traveling, particularly in developing countries  formally defined as  ≥ 3 loose stools in 24-hour period with  ≥ 1 accompanying systemic or enteric symptom, such as fever, nausea, vomiting, or abdominal cramps  bacteria account for majority of cases, but traveler's diarrhea may also be caused by parasites or viruses

3 Epidemiology  most common travel-associated disease, affecting 30%-70% of travelers  traveler's diarrhea most common illness among returned travelers  most frequent identified pathogens were Campylobacter, Salmonella, or Shigella  specific parasitic cause identified in 20%  most frequently identified parasite was Giardia

4 Risk Factors  travel destination is most significant risk factor for traveler's diarrhea  high-risk areas include South Asia, the Middle East, Africa, and Latin America  other risk factors for traveler's diarrhea include  poor hygiene and inadequate public health practices in handing or preparation of food and beverages in restaurants  inadequate electrical capacity, water supplies, or plumbing facilities  pregnancy  young age  achlorhydria or taking histamine H 2 blockers or proton pump inhibitors

5 Risk Factors  vegetables may be contaminated with coliform bacteria  based on analysis of raw and cooked vegetable samples from Mexico (64 samples) and Texas (67 samples)  comparing Mexico vs. Texas, coliform contamination  overall 42% vs. 25% (p = 0.04)  in cooked vegetables 67% vs. 10% (p < 0.001)  tabletop sauces may be contaminated with causative organisms of traveler's diarrhea  based on analysis of 96 samples of tabletop sauces from restaurants in Guadalajara, Mexico and Houston, Texas  Escherichia coli was grown from 40% of sauces from Texas vs. 66% from Mexico

6 Causes  traveler's diarrhea may be caused by bacterial, viral, and parasitic pathogens (1, 5)1 5  enterotoxigenic Escherichia coli (ETEC) is most common bacterial pathogen and may be causative organism in up to one- third of cases  Norovirus is most common viral pathogen  Giardia is most common parasitic pathogen

7 Causes  incubation period varies by causative organism  6-48 hours for most bacterial or viral infections  1-2 weeks for most parasitic infections  transmitted mainly through consumption of contaminated food or water  mechanism of disease varies with causative organism

8 Treatment  most cases are self-limited  severity of illness determines treatment approach, which focuses on  symptomatic treatment including symptomatic treatment  rehydration therapy (most often needed in elderly and very young patients) rehydration therapy  use of antimotility agents and bismuth  loperamide (Imodium) is the agent of choice (IDSA Grade A-I) loperamideIDSA Grade A-I  dosed at 4 mg orally then 2 mg after each loose stool (not to exceed 16 mg/day)

9 Treatment  empiric antibioticsantibiotics  antibiotics may reduce the duration of illness but may carry increased risk of side effects (level 2 [mid-level] evidence) antibiotics may reduce the duration of illness level 2 [mid-level] evidence  typically recommended for those with moderate-to-severe disease  fluoroquinolones are antibiotic class of choice in most cases (IDSA Grade A-I) fluoroquinolonesIDSA Grade A-I  azithromycin is an alternative, particularly when quinolone-resistant pathogens are a concern (such as with travel to Southeast Asia and India) (IDSA Grade B-I) azithromycinIDSA Grade B-I

10 Prevention  Food and beverage selection:  advise travelers on how to prevent diarrhea (IDSA Grade A-III)IDSA Grade A-III  seek out restaurants and eateries with excellent reputation for safety  choose foods that are piping hot, thoroughly cooked, dry, or personally peeled (fruits and vegetables)  choose beverages that are bottled and sealed, or carbonated; boiled beverages may also be safe to drink but iodine and chlorine may not be effective against some parasitic pathogens  avoid tap water, ice cubes, fruit juices, fresh salads, unpasteurized dairy products, cold sauces or toppings, open buffets, and undercooked or incompletely reheated foods  wash or otherwise clean hands (for example, using alcohol-based cleaners) after using the toilet and before eating  carrying small bottles of alcohol-based cleaners (≥ 60% alcohol) may make it easier to clean hands before eating

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