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Dallman TJ, Neuert S, Fernandez Turienzo C, Berin M, Richardson E, Fuentes-Utrilla P, Loman N, Gharbia S, Jenkins C, Behrens RH, Godbole G, Brown M. Prevalence and Persistence of Antibiotic Resistance Determinants in the Gut of Travelers Returning to the United Kingdom is Associated with Colonization by Pathogenic Escherichia coli. Microbiol Spectr 2023; 11:e0518522. [PMID: 37255437 PMCID: PMC10433802 DOI: 10.1128/spectrum.05185-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 05/11/2023] [Indexed: 06/01/2023] Open
Abstract
The gut microbiota constitutes an ideal environment for the selection, exchange, and carriage of antibiotic resistance determinants (ARDs), and international travel has been identified as a risk factor for acquisition of resistant organisms. Here, we present a longitudinal metagenomic analysis of the gut resistome in travellers to "high-risk" countries (Gutback). Fifty volunteers, recruited at a travel clinic in London, United Kingdom, provided stool samples before (pre-travel), immediately after (post-travel), and 6 months after their return (follow-up) from a high-risk destination. Fecal DNA was extracted, metagenomic sequencing performed and the resistome profiled. An increase in abundance and diversity of resistome was observed after travel. Significant increases in abundance were seen in antimicrobial genes conferring resistance to macrolides, third-generation cephalosporins, aminoglycosides, and sulfonamides. There was a significant association with increased resistome abundance if the participant experienced diarrhea during travel or took antibiotics, but these two variables were co-correlated. The resistome abundance returned to pre-travel levels by the 6-month sample point but there was evidence of persistence of several ARDs. The post-travel samples had an increase in abundance Escherichia coli which was positively associated with many acquired resistant determinants. Virulence and phylogenetic profiling revealed pathogenic E. coli significantly contributed to this increase abundance. In summary, in this study, foreign travel remains a significant risk factor for acquisition of microbes conferring resistance to multiple classes of antibiotics, often associated with symptomatic exposure to diarrhoeagenic E. coli. IMPORTANCE A future where antimicrobial therapy is severely compromised by the increase in resistant organisms is of grave concern. Given the variability in prevalence and diversity of antimicrobial resistance determinants in different geographical settings, international travel is a known risk factor for acquisition of resistant organisms into the gut microbiota. In this study, we show the utility of metagenomic approaches to quantify the levels of acquisition and carriage of resistance determinants after travel to a "high-risk" setting. Significant modulation to the resistome was seen after travel that is largely resolved within 6 months, although evidence of persistence of several ARDs was observed. Risk factors for acquisition included experiencing a diarrheal episode and the use of antibiotics. Colonization by pathogenic Escherichia coli was correlated with an increase in acquisition of antimicrobial resistance determinants, and as such established public health guidance to travelers on food and water safety remain an important message to reduce the spread of antibiotic resistance.
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Affiliation(s)
- Timothy J. Dallman
- Gastrointestinal Bacteria Reference Unit, UK Health Security Agency London, United Kingdom
- Faculty of Veterinary Medicine, Institute for Risk Assessment Sciences (IRAS), Utrecht University, Utrecht, the Netherlands
| | - Saskia Neuert
- Gastrointestinal Bacteria Reference Unit, UK Health Security Agency London, United Kingdom
- Gut Microbes and Health, Quadram Institute Bioscience, Norwich, United Kingdom
- National Institute for Health Research Health Protection Research Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, United Kingdom
| | - Cristina Fernandez Turienzo
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Division of Infection and Immunity, University College London, London, United Kingdom
- Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Michelle Berin
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - Emily Richardson
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, United Kingdom
- MicrobesNG, Birmingham, United Kingdom
| | - Pablo Fuentes-Utrilla
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, United Kingdom
- MicrobesNG, Birmingham, United Kingdom
| | - Nicholas Loman
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, United Kingdom
| | - Saheer Gharbia
- Gastrointestinal Bacteria Reference Unit, UK Health Security Agency London, United Kingdom
- National Institute for Health Research Health Protection Research Unit in Genomics and Enabling Data, Warwick University, United Kingdom
| | - Claire Jenkins
- Gastrointestinal Bacteria Reference Unit, UK Health Security Agency London, United Kingdom
- National Institute for Health Research Health Protection Research Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, United Kingdom
| | - Ron H. Behrens
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Gauri Godbole
- Gastrointestinal Bacteria Reference Unit, UK Health Security Agency London, United Kingdom
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Michael Brown
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Le Dault E, Sicard S, Desplans J, Mayet A, Simon F, Aigle L, Savini H, Coton T, Marimoutou C; TAMIDOPEX team. A single dose of ciprofloxacin reduces the duration of diarrhea among service members deployed in Africa. Infect Dis Now 2023; 53:104643. [PMID: 36642099 DOI: 10.1016/j.idnow.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/27/2022] [Accepted: 01/06/2023] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To assess the effectiveness of the adjunction of a one-gram single dose of ciprofloxacin to a symptomatic treatment for the early treatment of uncomplicated diarrhea during military operations of the French service members in Africa. PATIENTS AND METHODS This phase IV, multicentric, randomized, open-label, controlled trial was conducted in Chad, Mali, and in Central African Republic. A total of 267 French service members having at least one loose stool in the previous 24 hours were enrolled from May 2015 to June 2016. Participants were randomized to receive ciprofloxacin 1 g and a symptomatic treatment (racecadotril 100 mg three times a day and ad libidum oral rehydration solution) or a symptomatic treatment alone. The primary outcome was the duration of the diarrhea. Secondary outcomes were evaluated at the 72-hour endpoint and included recovery status, number of loose stools, frequency and duration of associated symptoms and safety of treatments. RESULTS Among 267 participants, 242 completed the trial. Participants receiving ciprofloxacin and a symptomatic treatment (n = 124) were significantly more likely to be cured at the endpoint than those who only received a symptomatic treatment (118): 94.4 % versus 74.6 % (OR = 5.7; 95 %CI: [2.4-13.6]; p < 10-3). The antibiotic therapy reduced the average diarrhea duration by 30 % (p = 10-4). Fever at inclusion was associated with a longer episode (HR = 0.61; 95 %CI: [0.41-0.89]; p = 0.012). No adverse event of medications was reported. CONCLUSION A single dose of ciprofloxacin was effective and safe in treating uncomplicated diarrhea among service members in Africa.
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Olson S, Hall A, Riddle MS, Porter CK. Travelers' diarrhea: update on the incidence, etiology and risk in military and similar populations - 1990-2005 versus 2005-2015, does a decade make a difference? Trop Dis Travel Med Vaccines 2019; 5:1. [PMID: 30675367 PMCID: PMC6332902 DOI: 10.1186/s40794-018-0077-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 12/20/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Travelers' diarrhea remains a prevalent illness impacting individuals visiting developing countries, however most studies have focused on this disease in the context of short term travel. This study aims to determine the regional estimates of travelers' diarrhea incidence, pathogen-specific prevalence, and describe the morbidity associated with diarrheal disease among deployed military personnel and similar long term travelers. METHODS We updated a prior systematic review to include publications between January 1990 and June 2015. Point estimates and confidence intervals of travelers' diarrhea and pathogen prevalence were combined in a random effects model and assessed for heterogeneity. Eighty-two studies were included in the analysis, including 29 new studies since the prior systematic review. RESULTS Military personnel were evaluated in 69% of studies and non-military long term travelers in 34%, with a median duration of travel of 4.9 months, and travel predominantly to the Middle East, Southeast Asia, and Latin America and the Caribbean. Sixty-two percent of tested cases were due to bacterial pathogens, with enterotoxigenic E. coli (ETEC), enteroaggregative E. coli (EAEC), and Campylobacter predominating, and significant regional variability. The incidence of TD from studies with longitudinal data was 36.3 cases per 100 person-months, with the highest rates in Southeast Asia, Latin America and the Caribbean, and the Middle East, with higher estimates from those studies using self-reporting of disease. Morbidity remained significant, with 21% being incapacitated or placed sick in quarters (SIQ) by their illness, 15% requiring intravenous fluids, and 3% requiring hospitalization. CONCLUSIONS In comparison to results from the prior systematic review, there were no significant differences in incidence, pathogen prevalence, or morbidity; however there was a trend toward improved care-seeking by sick individuals.
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Affiliation(s)
- Scott Olson
- Enteric Disease Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
| | - Alexis Hall
- Enteric Disease Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
| | - Mark S. Riddle
- Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Chad K. Porter
- Enteric Disease Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
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Beeching NJ, Carratalà J, Razonable RR, Oriol I, Vilela EG. Traveler's Diarrhea Recommendations for Solid Organ Transplant Recipients and Donors. Transplantation 2018; 102:S35-41. [PMID: 29381576 DOI: 10.1097/TP.0000000000002015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Abstract
Diarrheal disease affects a large proportion of military personnel deployed to developing countries, resulting in decreased job performance and operational readiness. Travelers' diarrhea is self-limiting and generally resolves within 5 days; however, antibiotic treatment significantly reduces symptom severity and duration of illness. Presently, azithromycin is the preferred first-line antibiotic for the treatment of acute watery diarrhea (single dose 500 mg), as well as for febrile diarrhea and dysentery (single dose 1,000 mg). Levofloxacin and ciprofloxacin are also options for acute watery diarrhea (single dose 500 mg and 750 mg, respectively) and febrile diarrhea/dysentery in areas with high rates of Shigella (500 mg once for 3 days [once daily with levofloxacin and twice daily with ciprofloxacin]), but are becoming less effective because of increasing fluoroquinolone resistance, particularly among Campylobacter spp. Another alternate for acute watery diarrhea is rifaximin (200 mg 3 times per day for 3 days); however, it should not be used with invasive illness. Use of loperamide in combination with antibiotic treatment is also beneficial as it has been shown to further reduce gastrointestinal symptoms and duration of illness. Because of regional differences in the predominance of pathogens and resistance levels, choice of antibiotic should take travel destination into consideration.
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Affiliation(s)
- David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
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Schwartz KL, Keystone JS. Protection of Travelers. Principles and Practice of Pediatric Infectious Diseases 2018. [PMCID: PMC7152348 DOI: 10.1016/b978-0-323-40181-4.00008-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Riddle CAPTMS, Martin GJ, Murray COLCK, Burgess CAPTTH, Connor CP, Mancuso COLJD, Schnaubelt MER, Ballard LCTP, Fraser J, Tribble DR. Management of Acute Diarrheal Illness During Deployment: A Deployment Health Guideline and Expert Panel Report. Mil Med 2017; 182:34-52. [PMID: 28885922 PMCID: PMC5657341 DOI: 10.7205/milmed-d-17-00077] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Acute diarrheal illness during deployment causes significant morbidity and loss of duty days. Effective and timely treatment is needed to reduce individual, unit, and health system performance impacts. METHODS This critical appraisal of the literature, as part of the development of expert consensus guidelines, asked several key questions related to self-care and healthcare-seeking behavior, antibiotics for self-treatment of travelers' diarrhea, what antibiotics/regimens should be considered for treatment of acute watery diarrhea and febrile diarrhea and/or dysentery, and when and what laboratory diagnostics should be used to support management of deployment-related travelers' diarrhea. Studies of acute diarrhea management in military and other travelers were assessed for relevance and quality. On the basis of this critical appraisal, guideline recommendations were developed and graded by the Expert Panel using good standards in clinical guideline development methodology. RESULTS New definitions for defining the severity of diarrhea during deployment were established. A total of 13 graded recommendations on the topics of prophylaxis, therapy and diagnosis, and follow-up were developed. In addition, four non-graded consensus-based statements were adopted. CONCLUSIONS Successful management of acute diarrheal illness during deployment requires action at the provider, population, and commander levels. Strong evidence supports that single-dose antimicrobial therapy is effective in most cases of moderate to severe acute diarrheal illness during deployment. Further studies are needed to address gaps in available knowledge regarding optimal therapies for treatment, prevention, and laboratory testing of acute diarrheal illness.
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Affiliation(s)
- CAPT Mark S. Riddle
- Enteric Disease Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA
| | - Gregory J. Martin
- Chief, Tropical Medicine-Infectious Diseases, Bureau of Medical Services, US Department of State, 2401 E St NW L209, Washington DC 20037, USA
| | - COL Clinton K. Murray
- Deputy Medical Corps Chief, Medical Corps Specific Branch Proponent Officer, Infectious Disease Consultant to the Army Surgeon General, Brooke Army Medical Center, 3551 Roger Brooke Dr, JBSA Fort Sam Houston, TX 78234, USA
| | - CAPT Timothy H. Burgess
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Col Patrick Connor
- Military Enteric Disease Group, Academic Department of Military Medicine, Birmingham Research Park, Vincent Drive, Birmingham B15 2SQ, United Kingdom
| | - COL James D. Mancuso
- Department of Preventive Medicine & Biostatistics, The F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Maj Elizabeth R. Schnaubelt
- Infectious Disease Service, Landstuhl Regional Medical Center, Landstuhl, Germany, CMR 402, APO, AE, 19180, USA [Current Affiliation: Division of Global HIV and TB, Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30333, USA]
| | - Lt Col Timothy P. Ballard
- Operational Medicine, Defense Institute for Medical Operations, 1320 Truemper St, Bldg 9122, JBSA-Lackland, TX 78236, USA
| | - Jamie Fraser
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Dr #100, Bethesda, MD 20817, USA
| | - David R. Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
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Riddle MS, Connor BA, Beeching NJ, DuPont HL, Hamer DH, Kozarsky P, Libman M, Steffen R, Taylor D, Tribble DR, Vila J, Zanger P, Ericsson CD. Guidelines for the prevention and treatment of travelers' diarrhea: a graded expert panel report. J Travel Med 2017; 24:S57-S74. [PMID: 28521004 PMCID: PMC5731448 DOI: 10.1093/jtm/tax026] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND : Travelers' diarrhea causes significant morbidity including some sequelae, lost travel time and opportunity cost to both travelers and countries receiving travelers. Effective prevention and treatment are needed to reduce these negative impacts. METHODS : This critical appraisal of the literature and expert consensus guideline development effort asked several key questions related to antibiotic and non-antibiotic prophylaxis and treatment, utility of available diagnostics, impact of multi-drug resistant (MDR) colonization associated with travel and travelers' diarrhea, and how our understanding of the gastrointestinal microbiome should influence current practice and future research. Studies related to these key clinical areas were assessed for relevance and quality. Based on this critical appraisal, guidelines were developed and voted on using current standards for clinical guideline development methodology. RESULTS : New definitions for severity of travelers' diarrhea were developed. A total of 20 graded recommendations on the topics of prophylaxis, diagnosis, therapy and follow-up were developed. In addition, three non-graded consensus-based statements were adopted. CONCLUSIONS : Prevention and treatment of travelers' diarrhea requires action at the provider, traveler and research community levels. Strong evidence supports the effectiveness of antimicrobial therapy in most cases of moderate to severe travelers' diarrhea, while either increasing intake of fluids only or loperamide or bismuth subsalicylate may suffice for most cases of mild diarrhea. Further studies are needed to address knowledge gaps regarding optimal therapies, the individual, community and global health risks of MDR acquisition, manipulation of the microbiome in prevention and treatment and the utility of laboratory testing in returning travelers with persistent diarrhea.
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Affiliation(s)
| | - Bradley A. Connor
- Weill Cornell Medical College and The New York Center for Travel and
Tropical Medicine, New York, NY, USA
| | - Nicholas J. Beeching
- Clinical Science Group, Liverpool School of Tropical Medicine, Pembroke
Place, Liverpool, UK and National Institute of Health Research (NIHR) Health Protection Unit
in Gastrointestinal Infections, Farr Institute, University of Liverpool, Liverpool, UK
| | | | - Davidson H. Hamer
- Department of Global Health, Center for Global Health and Development,
Boston University School of Public Health, Section of Infectious Diseases, Department of
Medicine, Boston University School of Medicine, Boston, MA, USA
| | | | - Michael Libman
- J.D. MacLean Centre for Tropical Diseases, McGill University, Montreal,
Québec, Canada
| | - Robert Steffen
- Epidemiology, Biostatistics and Prevention Institute, World Health
Organization Collaborating Centre for Traveller's Health, University of Zurich, Zurich,
Switzerland
| | | | - David R. Tribble
- Uniformed Services University of the Health Sciences, Bethesda, MD,
USA
| | - Jordi Vila
- ISGlobal, Barcelona Centre for International Health Research, Hospital
Clínic–Universitat de Barcelona, Barcelona, Spain
| | - Philipp Zanger
- Institute of Public Health, University Hospitals,
Ruprecht-Karls-Universität, Heidelberg, Germany
| | - Charles D. Ericsson
- Department of Medicine, Division of Infectious Diseases, University of
Texas Medical School at Houston, Houston, TX, USA
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Abstract
BACKGROUND. Travellers' diarrhoea (TD) is a common problem, affecting millions of tourists each year and creating a large economic burden. Risk factors for TD are known and guidelines exist to assist practitioners in advising travellers on how to prevent and treat TD. However, data are lacking regarding actual prescribing practices or approaches used in TD management. This study aims to establish a baseline which identifies uniformities and diversities in practice. METHODS. An online survey created using the SurveyMonkey tool was developed to test respondent approaches to TD pre-travel management. An invitation to participate in the survey was distributed early 2016 through selected Australian and New Zealand speciality travel medicine centres and through the electronic mailing list of the International Society of Travel Medicine (ISTM). Descriptive statistics and analyses using Chi Square analysis and two-sided Fishers exact tests for significance were used. RESULTS. Three hundred and sixty-four completed or partially completed surveys were collected from respondents in 23 countries. Approach to TD, antibiotic choice and management of four different clinical scenarios were assessed, with analyses focused on identifying significant differences in approach according to region of practice, professional background and level of experience. The responses to the clinical scenarios suggest most uniformity in recommended treatment strategies in clearly mild or severe disease, and greater variability in moderate disease. CONCLUSIONS. There is practice diversity in the discussion of preventative techniques and prescribing of self-treatment medications for TD, especially for moderate TD disease. Evidence-based guidelines that address the competing issues of patient health and morbidity vs the risk of colonization with resistant organisms may lead to more consistent antibiotic prescribing practices.
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Affiliation(s)
- Christian M McGrath
- Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Doherty Institute for Infection and Immunity, Parkville, VIC, Australia
| | - Karin Leder
- School of Public Health and Preventive Medicine, Monash University, Clayton VIC Australia
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Riddle MS, DuPont HL, Connor BA. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. Am J Gastroenterol 2016; 111:602-22. [PMID: 27068718 DOI: 10.1038/ajg.2016.126] [Citation(s) in RCA: 184] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 03/16/2016] [Indexed: 12/11/2022]
Abstract
Acute diarrheal infections are a common health problem globally and among both individuals in the United States and traveling to developing world countries. Multiple modalities including antibiotic and non-antibiotic therapies have been used to address these common infections. Information on treatment, prevention, diagnostics, and the consequences of acute diarrhea infection has emerged and helps to inform clinical management. In this ACG Clinical Guideline, the authors present an evidence-based approach to diagnosis, prevention, and treatment of acute diarrhea infection in both US-based and travel settings.
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Affiliation(s)
- Mark S Riddle
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Herbert L DuPont
- University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Bradley A Connor
- Weill Medical College of Cornell University, New York, New York, USA
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Lewis JM, Goodwin L, Beadsworth MBJ. The returning traveller with diarrhoea. Br J Hosp Med (Lond) 2014; 75:C133-6. [DOI: 10.12968/hmed.2014.75.9.c133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- JM Lewis
- Specialist Trainee in Infectious Diseases
| | - L Goodwin
- Specialist Trainee in Infectious Diseases
| | - MBJ Beadsworth
- Consultant in Infectious Diseases in the Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool L7 8XP
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Stienlauf S, Meltzer E, Kurnik D, Leshem E, Kopel E, Streltsin B, Schwartz E. Potential drug interactions in travelers with chronic illnesses: a large retrospective cohort study. Travel Med Infect Dis 2014; 12:499-504. [PMID: 24867407 DOI: 10.1016/j.tmaid.2014.04.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 04/09/2014] [Accepted: 04/24/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Data regarding the prevalence of potential interactions between travel-related medications (TRM) and chronic medications in use, or medical conditions of travelers to developing countries are limited. METHODS A retrospective cohort study of travelers to low income countries. We extracted data on demographics, travel destinations, use of chronic medications, drug allergies, and relevant medical conditions. The following TRM were evaluated: mefloquine, primaquine, doxycycline, atovaquone/proguanil, fluoroquinolone antibiotics, rifaximin, azithromycin, and acetazolamide. RESULTS A total of 16,263 travelers were included in the analysis, of whom 3299(20%) suffered from chronic illnesses and 2316(14%) reported chronic medication use. A potential drug-drug interaction with TRM was identified in 1047(45%) of travelers using chronic medication. Fluoroquinolones and azithromycin were the most commonly implicated TRMs. A potential medical condition interaction with TRM was identified in 717(22%) of travelers having chronic illnesses. acetazolamide, primaquine and mefloquine, were the most commonly TRMs implicated. Drug allergies, which can pose a relative contraindication for use of acetazolamide, were reported by 1323(8.1%) of all travelers. CONCLUSIONS Potential drug-drug and drug-disease interactions involving TRM might occur in a significant proportion of travelers with chronic medical conditions. Education of health practitioners regarding such potential drug interactions and caution when in prescribing travel-related medications is warranted.
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Affiliation(s)
- Shmuel Stienlauf
- The Center of Geographic Medicine, The Chaim Sheba Medical Center, Tel Hashomer 52621, Israel; The Departments of Internal Medicine, The Chaim Sheba Medical Center, Tel Hashomer 52621, Israel; The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel.
| | - Eyal Meltzer
- The Center of Geographic Medicine, The Chaim Sheba Medical Center, Tel Hashomer 52621, Israel; The Departments of Internal Medicine, The Chaim Sheba Medical Center, Tel Hashomer 52621, Israel; The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel.
| | - Daniel Kurnik
- The Departments of Internal Medicine, The Chaim Sheba Medical Center, Tel Hashomer 52621, Israel; The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel.
| | - Eyal Leshem
- The Center of Geographic Medicine, The Chaim Sheba Medical Center, Tel Hashomer 52621, Israel; The Departments of Internal Medicine, The Chaim Sheba Medical Center, Tel Hashomer 52621, Israel; The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel.
| | - Eran Kopel
- The Center of Geographic Medicine, The Chaim Sheba Medical Center, Tel Hashomer 52621, Israel; The Departments of Internal Medicine, The Chaim Sheba Medical Center, Tel Hashomer 52621, Israel.
| | - Bianca Streltsin
- The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel; The Arrow Project, The Chaim Sheba Medical Center, Tel Hashomer, 52621, Israel.
| | - Eli Schwartz
- The Center of Geographic Medicine, The Chaim Sheba Medical Center, Tel Hashomer 52621, Israel; The Departments of Internal Medicine, The Chaim Sheba Medical Center, Tel Hashomer 52621, Israel; The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel.
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Paulke-Korinek M, Kollaritsch H. Treatment of Traveler’s Diarrhea. Curr Treat Options Infect Dis 2013. [DOI: 10.1007/s40506-013-0002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
Travel medicine continues to grow as international tourism and patient medical complexity increases. This article reflects the state of the current field, but new recommendations on immunizations, resistance patterns, and treatment modalities constantly change. The US Centers for Disease Control and the World Health Organization maintain helpful Web sites for both patient and physician. With thoughtful preparation and prevention, risks can be minimized and travel can continue as safely as possible.
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Affiliation(s)
- Mayan Bomsztyk
- Department of Medicine, University of Washington, 4245 Roosevelt Way Northeast, Seattle, WA 98105, USA.
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Affiliation(s)
- Patrick Connor
- MDHU and Department of Gastroenterology, Frimley Park Hospital, Frimley, Surrey, UK
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Connor P, Porter CK, Swierczewski B, Riddle MS. Diarrhoea during military deployment: current concepts and future directions. Curr Opin Infect Dis 2012; 25:546-54. [PMID: 22907281 DOI: 10.1097/QCO.0b013e3283582ebc] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Diarrhoea among military travellers deployed globally in conflict and peacekeeping activities remains one of the most important health threats. Here we review recent advances in our understanding of the epidemiology, laboratory identification, treatment and chronic health consequences of this multi-cause infection, and consider the implications for public health management and future research. RECENT FINDINGS The incidence of diarrhoea among deployed military personnel from industrialized countries to lesser developed countries is approximately 30% per month overall, with clinical incidence between 5 and 7% per 100 person-months. The risk appears to be higher early during deployment and is associated with poor hygienic conditions and contaminated food sources. Gaps remain in our understanding of the cause, given the lack of laboratory capability in austere conditions of deployment; however, recent advances in molecular methods of characterization hold promise in improving our detection capabilities. While there have been improvements in understanding of best treatments, more work needs to be done in transforming this knowledge into action and optimizing single-dose antibiotic treatment regimens. Finally, the under-recognized burden of chronic consequences of these infections is gaining awareness and reinforces the need to find effective preventive strategies. SUMMARY Our understanding of the epidemiology of diarrhoea is improving but further research is needed to fully account for acute operational-focused health impacts as well as the chronic enduring disease impacts. Improved field diagnostics would be of great value to support these efforts.
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Crockett ME, Keystone JS. Protection of Travelers. Principles and Practice of Pediatric Infectious Diseases 2012. [PMCID: PMC7152291 DOI: 10.1016/b978-1-4377-2702-9.00008-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Abstract
Traveler's diarrhea (TD) strikes 20-60% of travelers visiting developing countries. It occurs shortly after the return and can be distinguished into two categories: acute and persistent TD. Acute TD, mostly caused by bacterial and viral pathogens, is usually mild and self-limited, and deserves empirical symptomatic and/or antibiotic therapy in selected cases. Fluoroquinolones are progressively superseded in this indication by azithromycin, a well tolerated macrolide active against most bacteria responsible for TD, including the quinolone-resistant species of Campylobacter jejuni that are now pervasive, especially in Southeast Asia and India. Persistent TD in the returning traveler is much rarer than its acute counterpart and may be associated with three types of causes. Persistent infections, among which Giardia and possibly Entamoeba predominate, account for a significant proportion of cases. Postinfectious processes represent a second cause and comprise temporary lactose malabsorption and postinfectious irritable bowel syndrome, now considered a major cause of persistent TD. Finally, apparently unrelated chronic diseases causing diarrhea are occasionally unmasked by TD and represent a third type of persistent TD, among which the well established case of incident inflammatory bowel disease poses intriguing pathogenesis questions. This review discusses recent advances in the field and provides practical recommendations for the management of TD in adult, immunocompetent returning travelers.
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Abstract
BACKGROUND Travellers' diarrhoea is the most common medical complaint among persons venturing into developing areas from industrialized regions. AIM To review recent developments dealing with microbiological, clinical, pathophysiological and therapeutic aspects of travellers' diarrhoea. METHODS The author's extensive file plus a review of publications listed in PubMed on January 22, 2009 on the topic of travellers' diarrhoea were reviewed. RESULTS Travellers' diarrhoea is largely caused by detectable and undetected bacterial enteropathogens, explaining the remarkable effectiveness of antibacterial agents in prophylaxis and therapy of the illness. A number of host genetic polymorphisms have been recently linked with susceptibility to travellers' diarrhoea. Novel antisecretory agents are being developed for treatment considering their physiological effects in acute diarrhoea. All travellers should be armed with one of three antibacterial drugs, ciprofloxacin, rifaximin or azithromycin, before their trips to use in self therapy should diarrhoea occur during travel. Loperamide may treat milder forms of travellers' diarrhoea and can be employed with antibacterial drugs. CONCLUSIONS Diarrhoea will continue to plague international travellers to high-risk regions. More studies of the incidence rate, relative important of the various pathogens by geographical region of the world, host risk factors and optimal therapeutic approach are needed.
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Affiliation(s)
- H L DuPont
- The University of Texas School of Public Health, St. Luke's Episcopal Hospital, Baylor College of Medicine, Houston, TX, USA.
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DuPont HL, Ericsson CD, Farthing MJG, Gorbach S, Pickering LK, Rombo L, Steffen R, Weinke T. Expert review of the evidence base for self-therapy of travelers' diarrhea. J Travel Med 2009; 16:161-71. [PMID: 19538576 DOI: 10.1111/j.1708-8305.2009.00300.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Herbert L DuPont
- Center for Infectious Disease, University of Texas School of Public Health at Houston, Houston, TX 77030, USA.
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Affiliation(s)
- Tracie Plant
- Birmingham University Medical School, Birmingham B15 2TT and
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Crockett ME, Keystone JS. Protection of Travelers. Principles and Practice of Pediatric Infectious Disease 2008. [PMCID: PMC7310923 DOI: 10.1016/b978-0-7020-3468-8.50015-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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26
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Abstract
Acute diarrhea associated with international travel is commonly caused by enterotoxigenic Escherichia coli, enteroaggregative E. coli, or noroviruses. Early studies to define these enteropathogens took place at the University of Maryland during the Theodore E. Woodward years. Although a reduction in the rate of diarrhea may be possible through avoidance of foods and beverages likely to be contaminated, a more effective preventive strategy is to administer nonabsorbed (<0.4%) rifaximin each day during trips to areas where the risk of traveler's diarrhea is high (i.e., high-risk areas). For the self-treatment of diarrhea that occurs during travel, all persons planning trips to high-risk areas should take with them medication with expected activity against the prevalent bacterial enteropathogens: rifaximin (for the treatment of common afebrile, nondysenteric diarrhea), a fluoroquinolone, or azithromycin. Further study is needed to determine whether it is possible to avoid important morbidity associated with diarrhea and the development of postinfectious irritable bowel syndrome with chemoprophylaxis and/or early effective treatment.
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Affiliation(s)
- Herbert L DuPont
- Center for Infectious Diseases, University of Texas-Houston School of Public Health, Houston, TX, USA.
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McMahan ZH, DuPont HL. Review article: the history of acute infectious diarrhoea management--from poorly focused empiricism to fluid therapy and modern pharmacotherapy. Aliment Pharmacol Ther 2007; 25:759-69. [PMID: 17373914 DOI: 10.1111/j.1365-2036.2007.03261.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Acute diarrhoea management has progressed from largely ineffective measures in the early years to a more effective physiologic approach in recent years. AIM To review the history of acute diarrhoea management. METHODS Citations in PubMed were reviewed on 'acute diarrhoea treatment' along with an extensive file maintained by the corresponding author. RESULTS Freedom from diarrhoea was equated in early military conflicts with bravery and strength where diarrhoea-free soldiers had the 'guts' to fight. Until early 20th century, colonic irrigants, purgatives and emetic drugs were used to help eliminate undesired intestinal contents. Only a few early authorities suggested the need for replacement of fluids and salt, now standard treatment. Drugs aimed at diarrhoea symptom control have been broadly used for more than 100 years. The evolving history of one of those drugs, kaopectate is unappreciated. Once understanding the pathophysiology and infectious aetiology of acute diarrhoea, new oral fluids, pharmacologic agents designed to block specific secretory alterations and anti-infective drugs have been identified. CONCLUSIONS Physiologic and antimicrobial approaches to controlling diarrhoea can lead to reduction of stool number and enteric complaints, important in industrialized areas, with the potential for decreasing threat of fatal illness among infants in developing regions.
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Affiliation(s)
- Z H McMahan
- University of Texas Southwestern, Dallas, TX, USA
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Hill DR, Ericsson CD, Pearson RD, Keystone JS, Freedman DO, Kozarsky PE, DuPont HL, Bia FJ, Fischer PR, Ryan ET. The Practice of Travel Medicine: Guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006; 43:1499-539. [PMID: 17109284 DOI: 10.1086/508782] [Citation(s) in RCA: 188] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2006] [Accepted: 08/23/2006] [Indexed: 12/17/2022] Open
Affiliation(s)
- David R Hill
- National Travel Health Network and Centre, London School of Hygiene and Tropical Medicine, London, WC1E 6AU, England.
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29
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Affiliation(s)
- Deepak Kamat
- Wayne State University, Institute of Medical Education, Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Detroit 48201, USA.
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Briand V, Buffet P, Genty S, Lacombe K, Godineau N, Salomon J, Vandemelbrouck E, Ralaimazava P, Goujon C, Matheron S, Fontanet A, Bouchaud O. Absence of efficacy of nonviable Lactobacillus acidophilus for the prevention of traveler's diarrhea: a randomized, double-blind, controlled study. Clin Infect Dis 2006; 43:1170-5. [PMID: 17029137 DOI: 10.1086/508178] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2006] [Accepted: 07/10/2006] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Diarrhea is the most common illness associated with international tourism. We evaluated the efficacy of a probiotic preparation of nonviable Lactobacillus acidophilus (hereafter referred to as LA) for the prevention of traveler's diarrhea. METHODS We conducted a randomized, double-blind, controlled trial. Travelers were randomized to receive either LA or placebo twice daily from 1 day before their departure to 3 days after their return. On each day of the trip and the week following the return, travelers had to record the number and consistency of stools and their adherence to the treatment. Diarrhea was defined as > or =3 unformed stools in a 24-h period. RESULTS From January 2001 to September 2004, a total of 174 subjects were randomized to each treatment group. Half of the travelers went to West Africa, and organized tours or backpacking were the most common modes of traveling. The incidence of diarrhea did not differ between the 2 groups; it was 61.4 cases per 100 person-months in the LA group (95% confidence interval [CI], 44.1-85.5) and 43.4 cases per 100 person-months in the placebo group (95% CI, 30.0-62.9) (P=.14). Adjustment for travel duration and other variables did not reveal any difference between the 2 groups (adjusted hazard ratios comparing the LA and placebo groups were 1.43 [95% CI, 0.87-2.36] in an intent-to-treat analysis and 1.38 [95% CI, 0.79-2.39] in an efficacy analysis). CONCLUSIONS There was no beneficial effect of treatment with LA for the prevention of travelers' diarrhea. More studies are required to assess the efficacy of other specific probiotics (e.g., a Lactobacillus rhamnosus GG preparation) for preventing traveler's diarrhea.
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Affiliation(s)
- Valérie Briand
- Emerging Diseases Epidemiology Unit, Institut Pasteur, Paris, France.
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31
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Abstract
Diarrhea continues to be the leading health problem among international travelers to developing tropical and semi-tropical regions. Despite more than 50 years of research providing information about the etiology and pathogenesis of the disease, the rate of illness and consequences remain unchanged. An estimated 40% of travelers to developing nations will become ill with diarrhea. Although travelers' diarrhea is considered a self-limited disease, novel and effective approaches to disease prevention and treatment have been realized in recent years. Also, recent evidence has identified a potential for long-term complications of the illness, including postinfectious irritable bowel syndrome. With the advent of poorly absorbed (<0.4%) rifaximin, a treatment option for the common watery diarrhea syndrome equivalent to previously used absorbed antibacterial drugs has emerged. Rifaximin with an excellent safety profile and limited potential to induce coliform resistance, prevents most of the diarrhea that would otherwise occur. With further studies in different settings, new consideration should be given to the routine use of chemoprophylaxis for travelers to high-risk countries. Antibacterial drugs will continue to be the optimal treatment for travelers' diarrhea subjects for the most part caused by bacterial enteropathogens and shorten the duration of diarrhea by 1-2 days compared with no active drug treatment.
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Affiliation(s)
- Hoonmo L Koo
- Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
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32
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Abstract
Of the millions who travel from the industrialized world to developing countries every year, between 20% and 50% will develop at least one episode of diarrhea, making it the most common medical ailment afflicting travelers. Although usually a mild illness, traveler's diarrhea can result in significant morbidity and hardship overseas. Precautions can be taken to minimize the risk of developing traveler's diarrhea, either through avoidance of potentially contaminated food or drink or through various prophylactic measures, including both nonpharmacological and antimicrobial strategies. If diarrhea does develop despite the precautions taken, effective treatment-usually a combination of an antibiotic and an antimotility agent-can be brought by the traveler and initiated as soon as symptoms develop. In the future, vaccines-several of which are in the advanced stages of clinical testing-may be added to the list of prophylactic measures.
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Affiliation(s)
- David J Diemert
- Human Hookworm Vaccine Initiative, Sabin Vaccine Institute, 1889 F St. NW, Suite 200S, Washington, DC 20006, USA.
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33
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34
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Abstract
Since first studied more than 5 decades ago the risk of travelers'diarrhea for persons going from industrialized regions to developing countries has remained high. Most cases of illness are caused by bacterial agents. Travelers' diarrhea is associated with temporary disability and it may progress to chronic intestinal illness and postinfectious irritable bowel syndrome. Exercising care about food and beverage intake, the use of rifaximin prophylaxis for selective patients, and self-treatment of all resultant illness will continue to be the way in which the disease is prevented or managed best by travelers. Future approaches will be aimed at making host regions safer and providing more effective methods of treatment and prevention of enteric disease during short-term international travel.
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Affiliation(s)
- Herbert L DuPont
- St. Luke's Episcopal Hospital, 6270 Bertner Avenue, Houston, TX 77030, USA.
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35
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Rockabrand DM, Shaheen HI, Khalil SB, Peruski LF, Rozmajzl PJ, Savarino SJ, Monteville MR, Frenck RW, Svennerholm AM, Putnam SD, Sanders JW. Enterotoxigenic Escherichia coli colonization factor types collected from 1997 to 2001 in US military personnel during operation Bright Star in northern Egypt. Diagn Microbiol Infect Dis 2006; 55:9-12. [PMID: 16542813 DOI: 10.1016/j.diagmicrobio.2005.12.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2005] [Revised: 12/06/2005] [Accepted: 12/06/2005] [Indexed: 11/27/2022]
Abstract
Operation Bright Star (OBS) is a biennial, multinational exercise in Egypt involving 15000 US troops. Consistent with past observations in deployed troops, diarrhea is the most significant cause of morbidity. Focused efforts are ongoing to develop vaccines against the most common pathogens affecting our troops. As part of these efforts, diarrhea surveillance was conducted during OBS to monitor pathogens associated with illness and to identify new vaccine targets. A retrospective review was conducted of prior studies with similar methods. Soldiers with diarrhea presenting to the OBS clinic provided a stool sample that was inoculated into Carey-Blair transport media. Within 3 days, the Cary-Blair tubes were transported to the Naval Medical Research Unit no. 3 in Cairo where bacterial culture was performed. As part of the evaluation, 5 Escherichia coli-like colonies were collected and tested for toxin production using the GM1-ELISA. Toxin-positive isolates were further tested for colonization factors (CF) by a dot-blot assay using a standardized panel of monoclonal antibodies against CFA/I, CS1-CS7, CS17, CS8 (CFA/III), CS12 (PCFO159), and CS14 (PCFO166). Enterotoxigenic E. coli (ETEC) was the most frequently isolated pathogen during each OBS from which data were collected. The rate of ETEC-associated diarrhea ranged from 22% to 58%. Over time, there were dramatic shifts in the frequency and distribution of CFs. Over the 5 years of study, an increasing number of ETEC isolates had no known CF identified, and in 2001, only 40% of ETEC was associated with known CFs. The most commonly identified CF was CS6. Diarrheal disease, particularly ETEC, continues to be a common malady among US military personnel deployed to Egypt. We have identified ETEC CF types, especially CS6, which should be considered potential vaccine candidates. However, despite intensive testing, CFs could not be identified in most of the ETEC isolated, highlighting the need for further studies to identify novel CFs and alternative vaccine targets.
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36
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Abstract
Travelers' diarrhea occurs when persons move from industrialized regions to developing countries with reduced hygiene. Bacterial enteropathogens from ingested food are the primary causes. Although it is possible to reduce the occurrence of illness by careful selection of food and beverages, travelers do not seem willing to restrict their diets. Diarrhea is associated with a disability of 24 hours per episode, interfering with travel plans and, of even greater concern, post-diarrhea irritable bowel syndrome (IBS) occurs in up to 10% of patients. The use of rifaximin, a poorly absorbed drug, is likely to become common as an attempt to prevent diarrhea and post-infectious IBS. All travelers to high-risk areas should take with them an effective antibacterial drug (rifaximin, fluoroquinolones, or azithromycin) for self-treatment of diarrhea occurring during travel. Additional work is needed to improve the hygienic conditions found in the developing world into which susceptible persons travel.
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Affiliation(s)
- Andrew W DuPont
- University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0764, USA.
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37
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Abstract
Traveller's diarrhoea affects over 50% of travellers to some destinations and can disrupt holidays and business trips. This review examines the main causes and epidemiology of the syndrome, which is associated with poor public health infrastructure and hygiene practices, particularly in warmer climates. Although travellers may be given common sense advice on avoidance of high-risk foods and other measures to prevent traveller's diarrhoea, adherence to such advice is sometimes difficult and the evidence for its effectiveness is contradictory. However, non-antimicrobial means for prevention of traveller's diarrhoea are favoured in most settings. A simple stepwise approach to the management of traveller's diarrhoea includes single doses or 3-day courses of antimicrobials, often self administered. The antibiotics of choice are currently fluoroquinolones or azithromycin, with an emerging role for rifaximin. In the long term, there will be greater benefit and effect on the health of local inhabitants and travellers from improving public health and hygiene standards at tourist destinations.
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Affiliation(s)
- Seif S Al-Abri
- Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK.
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38
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Abstract
TD has not proved as preventable as hoped, despite knowing that it is transmitted mainly through food. Travelers have little ability to select restaurants based on the kitchen hygiene. The rates of TD in travelers to developing countries have not changed in the past 50 years, either because the dietary precautions they are taught are not effective or they cannot be adhered to in the course of a pleasurable vacation. Nonantibiotic prophylaxis with bismuth subsalicylate has the potential to prevent 40% to 60% of TD episodes in short-term travelers, and is probably underused. Antibiotic prophylaxis can prevent up to 90% of infections, but is not routinely recommended. Empiric treatment of TD has been the best approach to dealing with this problem, but its usefulness is being undermined by growing antibiotic resistance in many parts of the world. Fluoroquinolones are still the most useful agents where Campylobacter is not a predominant pathogen. Rifaximin may prove to be a useful addition to the options for treatment and prophylaxis. If used for treatment, it may require a backup antibiotic in areas where Campylobacter and Shigella are prominent pathogens.
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Affiliation(s)
- David R Shlim
- Jackson Hole Travel and Tropical Medicine, PO Box 40, Kelly, WY 83011, USA.
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DuPont HL. Travelers' diarrhea: antimicrobial therapy and chemoprevention. ACTA ACUST UNITED AC 2005; 2:191-8; quiz 1 p following 198. [PMID: 16265184 DOI: 10.1038/ncpgasthep0142] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2005] [Accepted: 03/14/2005] [Indexed: 12/21/2022]
Abstract
The use of preventive measures and self-treatment for travelers' diarrhea is routine in regions where the occurrence of diarrhea is predictably high. People traveling to these areas who do not exercise care in their selection of consumed foods and beverages will suffer high rates of illness. Such diarrhea normally affects the traveler for a day, although it can result in chronic postinfectious irritable bowel syndrome. Although systemic antibacterial drugs are effective in preventing diarrhea, their use is not routinely recommended because of side effects and their importance as a therapy for extra-intestinal infections. This review focuses on current and future uses of antibacterial drugs in the prevention and therapy of travelers' diarrhea. Minimally absorbed (< 0.4%) rifaximin can effectively reduce the occurrence of travelers' diarrhea without side effects. Bismuth subsalicylate is a useful alternative, although it is less effective than rifaximin for the prevention of travelers' diarrhea and the required doses are less convenient. All people who travel to high-risk areas should take curative antimicrobial agents with them for self-treatment of illness: rifaximin 200 mg three times a day for 3 days, or an absorbable agent such as a fluoroquinolone or azithromycin taken in a single dose initially, with the need for a second or third dose determined by clinical response. Loperamide (up to 8 mg per day for < or = 2 days) can be given with the antibiotic to offer rapid symptomatic improvement. In the future, the ability to evaluate the genetic risk of illness acquisition might allow person-specific recommendations to be made.
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Affiliation(s)
- Anna C Casburn-Jones
- Department of Medicine, Gardiner Institute, Western Infirmary, University of Glasgow, Glasgow, UK.
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41
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Adachi JA, Ericsson CD, Jiang ZD, DuPont MW, Martinez-Sandoval F, Knirsch C, DuPont HL. Azithromycin Found to Be Comparable to Levofloxacin for the Treatment of US Travelers with Acute Diarrhea Acquired in Mexico. Clin Infect Dis 2003; 37:1165-71. [PMID: 14557959 DOI: 10.1086/378746] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2003] [Accepted: 06/18/2003] [Indexed: 11/04/2022] Open
Abstract
Increased drug resistance among enteropathogens is an emergent problem in travelers' diarrhea. This randomized, double-blind trial was conducted in Guadalajara, Mexico, during the summers of 1999-2001 to compare azithromycin with levofloxacin for the treatment of travelers' diarrhea. A total of 217 US adults were randomized to receive a single oral dose of azithromycin (1000 mg; 108 persons) or levofloxacin (500 mg; 109 persons), with a follow-up period of 4 days. Three patients in each group dropped out of the study. The median time between initiation of therapy and passage of the last unformed stool (azithromycin group, 22.3 h; levofloxacin group, 21.5 h) and the number of unformed stools passed during the 4-day follow-up period (azithromycin group, 6.5; levofloxacin group, 5.5) were similar. Treatment failure occurred in 10 patients (9.5%) receiving azithromycin and 8 patients (7.5%) receiving levofloxacin. Possible minor, self-limiting adverse events occurred in 57 patients in each treatment group. Azithromycin was found to be a safe and effective alternative to levofloxacin for the treatment of acute travelers' diarrhea in US adult travelers to Mexico.
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Affiliation(s)
- Javier A Adachi
- Center for Infectious Diseases, University of Texas-Houston School of Public Health and Medical School, Houston, Texas, USA
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42
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Krausse R, Ullmann U. In vitro activities of new fluoroquinolones against Campylobacter jejuni and Campylobacter coli isolates obtained from humans in 1980 to 1982 and 1997 to 2001. Antimicrob Agents Chemother 2003; 47:2946-50. [PMID: 12936999 PMCID: PMC182638 DOI: 10.1128/aac.47.9.2946-2950.2003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The antibacterial activities of three newly developed fluoroquinolones (gatifloxacin, levofloxacin, and moxifloxacin) against a total of 307 gastrointestinal human isolates of Campylobacter jejuni and Campylobacter coli collected during 1980 to 1982 and 1997 to 2001 were examined and compared to those of ciprofloxacin and the unrelated antibacterial agents, clarithromycin, erythromycin, and tetracycline by using the agar plate dilution method. All of the fluoroquinolones exhibited a good activity against Campylobacter, and some of them were more active than ciprofloxacin, the macrolides, and tetracycline. Among the fluoroquinolones, gatifloxacin and moxifloxacin showed the highest anticampylobacter activity, with MICs at which 50% of the isolates tested are inhibited (MIC(50)s) and MIC(90)s of 0.125 and 4 microg/ml, respectively; the MIC(50) for both levofloxacin and ciprofloxacin was 0.25, and the MIC(90)s were 16 and 32 microg/ml, respectively. About 30% of the strains were found to be resistant to at least one fluoroquinolone. Resistance to gatifloxacin occurred in 9.8% of the isolates tested, and resistance to the other fluoroquinolones occurred in 19.9 to 27.4% of the isolates tested; the frequency of cross-resistance was 35.7 to 100%. An increase in fluoroquinolone resistance from 0% in 1980 to 1982 to 11.8 to 29% in 1997 and 1998, 8.2 to 31.8% in 1999 and 2000, and 12.1 to 30.3% in 2001 was found. A total of 61.4 to 73.2% of the C. jenuni strains resistant to erythromycin, clarithromycin, and/or tetracycline were susceptible to fluoroquinolones; gatifloxacin showed the highest percentage of inhibition. These results show that the newer fluoroquinolones with their potent activity could be used to treat infections with C. jejuni and C. coli. However, when these drugs are used, one must consider the increase in resistance and the high cross-resistance to these antimicrobial agents.
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Affiliation(s)
- Rea Krausse
- Institute of Medical Microbiology and Virology, The University of Kiel, 24105 Kiel, Germany.
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44
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Abstract
Diarrhea is the most common medical problem affecting all travellers to developing countries. Younger children are at especially high risk of acquiring travellers' diarrhea and of suffering more severe consequences. Up to 50% of travellers from developed to developing countries can expect to have at least one episode of acute diarrhea during a two-week stay. Episodes of travellers' diarrhea usually begin abruptly, either during travel or soon after returning home, and are generally self-limited.
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45
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Affiliation(s)
- Robert Steffen
- Division of Communicable Diseases, World Health Organization Collaborating Centre for Travellers' Health, Institute of Social and Preventive Medicine of the University, Zurich, Switzerland
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46
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Abstract
Of the 50 million people who travel from the industrialized world to developing countries every year, between 20% and 50% will develop at least one episode of diarrhea, making it the most common ailment of travel. Although usually a mild illness, travelers' diarrhea can result in significant morbidity and hardship while overseas. Precautions can be taken to minimize the risk of developing diarrhea. If diarrhea does develop despite precautions, effective treatment, usually a combination of an antibiotic and an antimotility agent, can be taken along and started by the traveler at the onset of symptoms.
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Affiliation(s)
- David J Diemert
- Malaria Vaccine Development Unit, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Twinbrook I, Room 1123, 5640 Fishers Lane, Rockville, MD 20852, USA.
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47
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Affiliation(s)
- Lluís Valerio
- Unidad de Salud Internacional, Dirección de Atención Primaria Santa Coloma de Gramenet, Barcelona, Spain.
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48
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Abstract
Diarrhea is one of the most common health problems among travelers. Although enterotoxigenic Escherichia coli is implicated most commonly, enteroaggregative E. coli has recently been described as a major pathogen. Shigella, Campylobacter, and Salmonella organisms are less common causes of acute diarrhea, and intestinal protozoa are typical causes of protracted diarrhea. Although education is the mainstay of prevention measures, behavior modification has been shown to be difficult. Chemoprevention is rarely required with the availability of effective treatment, but there has been some interest in the use of vaccines. Maintenance of hydration is most important in children. In addition to bismuth preparations and loperamide, newer agents being developed for symptomatic relief include zaldaride maleate and racecadotril. Fluoroquinolones effectively treat severe traveler's diarrhea, and even a single dose may be sufficient. However, with the emergence of resistance, particularly in Campylobacter infection, other agents are required; interest has focused on azithromycin and rifaximin.
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Affiliation(s)
- Allen C. Cheng
- Room 0376, Orange Zone, Box 3152, Duke South, Division of Infectious Diseases, Duke University Medical Center, Durham, NC 27710, USA.
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49
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Abstract
Infectious diarrhea is a significant cause of morbidity and mortality and a common complaint in clinical practice. Routine empirical use of antibiotics for infectious diarrhea should be avoided because of the self-limited nature of most cases, the cost of antibiotics, and the potential to worsen the already significant problem of antibiotic resistance of enteric pathogens. For patients with severe invasive or prolonged diarrhea or who are at high risk of complications, such as the elderly, diabetics, cirrhotics, and immunocompromised patients, empirical treatment with a quinolone antibiotic for 3 to 5 days can be considered. Antibiotic treatment can be highly effective for Shigella, ETEC, and V. cholerae infections, and metronidazole is indicated for C. difficile colitis. The impact of antibiotics for other specific pathogens is modest, and antibiotic therapy should be reserved for the same group of patients who would be considered for empirical treatment. The most significant problem in the antibiotic treatment of infectious diarrhea is the progressive increase in resistance among enteric pathogens; only the prudent use of antimicrobials in all areas of daily practice can limit or delay the impact of this serious problem.
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Affiliation(s)
- E C Oldfield
- Infectious Disease Division, Department of Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
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50
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Abstract
Acute uncomplicated diarrhoea is commonly treated by self-medication. Guidelines for treatment exist, but are inconsistent, sometimes contradictory, and often owe more to dogma than evidence. An ad hoc multidisciplinary group has reviewed the literature to determine best practice. In general it is recognized that treatment of acute episodes relieves discomfort and social dysfunction. There is no evidence that it prolongs the illness. Self-medication in otherwise healthy adults is safe. Oral loperamide is the treatment of choice. Older anti-diarrhoeal drugs are also effective in the relief of symptoms but carry the risk of unwanted adverse effects. Oral rehydration solutions do not relieve diarrhoea, and confer no added benefit for adults who can maintain their fluid intake. Probiotic agents are, at present, limited in efficacy and availability. Antimicrobial drugs, available without prescription in some countries, are not generally appropriate for self-medication, except for travellers on the basis of medical advice prior to departure. Medical intervention is recommended for the management of acute diarrhoea in the frail, the elderly (> 75 years), persons with concurrent chronic disease, and children. Medical intervention is also required when there is no abatement of the symptoms after 48 h, or when there is evidence of deterioration such as dehydration, abdominal distension, or the onset of dysentery (pyrexia > 38.5 degrees C and/or bloody stools).
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Affiliation(s)
- D Wingate
- St Bartholomew's and the Royal London School of Medicine and Dentistry, Gastrointestinal Science Research Unit, London, UK.
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