Diarrhea in the returned traveller: Difference between revisions

Latest revision as of 22:47, 7 February 2022

Background

Microbiology

Bacteria
- Escherichia coli (entero-hemorragic (EHEC), entero-toxigenic (ETEC)): most common cause
  - Usually afebrile
  - Diffusely adherent E. coli (DAEC) also exists
- Campylobacter jejuni: more common in SE Asia
- Salmonella (non-typhoidal)
- Shigella
- Plesiomonas (unclear if cause of diarrhea)
- Vibrio cholerae
- Aeromonas
Viruses
- Norovirus: most common virus
- Rotavirus
- Enterovirus
Parasites
- Giardia lamblia: usually afebrile
- Entamoeba histolytica
- Cyclospora cayetanensis
- Cryptosporidium
- Strongyloides stercoralis
And others 1

Epidemiology

Usually defined as diarrhea (3 or more unformed stools per day), plus one of abdominal cramps, tenesmus, nausea, vomiting, fever, or fecal urgency, either while travelling
Incidence among travellers from rich countries is 10 to 40%

Risk Factors

Beach vacations are protective compared to VFR, adventure tours, or all-inclusive hotels
Cruise ships are associated with explosive outbreaks of norovirus
Lower rates in winter; higher during rainy seasons
Higher rates of diarrhea requiring hospitalization in infants and toddlers

Investigations

Blood cultures (if febrile)
Stool culture or PCR for bacteria
Stool for ova & parasites

Management

If mild (1-3 stools daily with mild enteric symptoms), can treat with bismuth subsalicylate or loperamide
- Avoid loperamide in patients less than 2 years, if they are febrile, or if their stools are bloody
May benefit from antibiotics if diarrhea is severe, there are systemic symptoms, or it is interfering with their activities
- Can decrease duration of diarrhea by about a day and a half
Empiric treatment depends on country of origin
- Ciprofloxacin 500 mg PO bid for 3 days, for countries with lower rates of resistance
- Azithromycin 500 to 1000 mg PO daily for 3 days

References

^ Nipam Shah, David J. Ramsey, Herbert L. DuPont. Global Etiology of Travelers’ Diarrhea: Systematic Review from 1973 to the Present. The American Journal of Tropical Medicine and Hygiene. 2009;80(4):609-614. doi:10.4269/ajtmh.2009.80.609.

@@ Line 1: / Line 1: @@
+==Background==
-= Diarrhea in the returned traveller =
+===Microbiology===
+*Bacteria
-== Differential Diagnosis ==
+**[[Escherichia coli]] (entero-hemorragic (EHEC), entero-toxigenic (ETEC)): most common cause
+***Usually afebrile
+***Diffusely adherent E. coli (DAEC) also exists
+**[[Campylobacter jejuni]]: more common in SE Asia
+**[[Salmonella]] (non-typhoidal)
+**[[Shigella]]
+**[[Plesiomonas]] (unclear if cause of diarrhea)
+**[[Vibrio cholerae]]
+**[[Aeromonas]]
+*Viruses
+**[[Norovirus]]: most common virus
+**[[Rotavirus]]
+**[[Enterovirus]]
+*Parasites
+**[[Giardia lamblia]]: usually afebrile
+**[[Entamoeba histolytica]]
+**[[Cyclospora cayetanensis]]
+**[[Cryptosporidium]]
+**[[Strongyloides stercoralis]]
+*And others [[CiteRef::shah2009gl]]
+===Epidemiology===
-* Bacteria
-** ''Escherichia coli'' (entero-hemorragic (EHEC), entero-toxigenic (ETEC)): most common cause
+*Usually defined as diarrhea (3 or more unformed stools per day), plus one of abdominal cramps, tenesmus, nausea, vomiting, fever, or fecal urgency, either while travelling
-*** Usually afebrile
+*Incidence among travellers from rich countries is 10 to 40%
-*** Diffusely adherent E. coli (DAEC) also exists
-** ''Campylobacter jejuni'': more common in SE Asia
+===Risk Factors===
-** ''Salmonella'' (non-typhoidal)
-** ''Shigella''
+*Beach vacations are protective compared to VFR, adventure tours, or all-inclusive hotels
-** ''Plesiomonas'' (unclear if cause of diarrhea)
+*Cruise ships are associated with explosive outbreaks of [[norovirus]]
-** ''Vibrio cholerae''
+*Lower rates in winter; higher during rainy seasons
-* Viruses
+*Higher rates of diarrhea requiring hospitalization in infants and toddlers
-** Noroviruses: most common virus
-* Parasites
+==Investigations==
-** ''Giardia lamblia'': usually afebrile
-** ''Entamoeba histolytica''
+*Blood cultures (if febrile)
-** ''Cyclospora cayetanensis''
+*Stool culture or PCR for bacteria
-** ''Cryptosporidium''
+*Stool for ova & parasites
-** ''Strongyloides stercoralis''
+==Management==
+*If mild (1-3 stools daily with mild enteric symptoms), can treat with [[bismuth subsalicylate]] or [[loperamide]]
+**Avoid [[loperamide]] in patients less than 2 years, if they are febrile, or if their stools are bloody
+*May benefit from [[antibiotics]] if diarrhea is severe, there are systemic symptoms, or it is interfering with their activities
+**Can decrease duration of diarrhea by about a day and a half
+*Empiric treatment depends on country of origin
+**[[Is treated by::Ciprofloxacin]] 500 mg PO bid for 3 days, for countries with lower rates of resistance
+**[[Is treated by::Azithromycin]] 500 to 1000 mg PO daily for 3 days
+==Further Reading==
+*Traveler's Diarrhea: A Clinical Review. ''JAMA''. 2015;313(1):71-80. doi: [https://doi.org/10.1001/jama.2014.17006 10.1001/jama.2014.17006]
+*Statement on Travellers' Diarrhea by the Committee to Advise on Tropical Medicine and Travel (CATMAT) ([https://www.canada.ca/en/public-health/services/catmat/statement-travellers-diarrhea.html available online])
+[[Category:Returned travellers]]
+[[Category:Gastrointestinal infections]]