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TRAVELER S DIARRHEA
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ESSENTIALS OF DIAGNOSIS
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Usually a benign, self-limited disease occurring about 1 week into travel Prophylaxis not recommended unless there is a comorbid disease (inflammatory bowel syndrome, HIV, immunosuppressive medication) Single-dose therapy of a fluoroquinolone usually effective if symptoms develop
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Whenever a person travels from one country to another particularly if the change involves a marked difference in climate, social conditions, or sanitation standards and facilities diarrhea may develop within 2 10 days Bacteria cause 80% of cases of traveler s diarrhea, with enterotoxigenic E coli, Shigella species, and Campylobacter jejuni being the most common pathogens Less common are Aeromonas, Salmonella, noncholera vibriones, E histolytica, and G lamblia Contributory causes include unusual food and drink, change in living habits, occasional viral infections (adenoviruses or rotaviruses), and change in bowel flora Chronic watery diarrhea may be due to amebiasis or giardiasis or, rarely, tropical sprue
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A Symptoms and Signs
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There may be up to ten or even more loose stools per day, often accompanied by abdominal cramps and nausea, occasionally by vomiting, and rarely by fever The stools are usually watery and not associated with fever when caused by entertoxigenic E coli With invasive bacterial pathogens (Shigella, Campylobacter, Salmonella) stools can be bloody and fever may be present The illness usually subsides spontaneously within 1 5 days, although 10% remain symptomatic for 1 week or longer, and symptoms persist for longer than 1 month in 2% Traveler s diarrhea is also a significant risk factor for developing irritable bowel syndrome
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For most individuals, the affliction is short-lived, and symptomatic therapy with opioids or loperamide is all that is required, provided the patient is not systemically ill (fever 39 C) and does not have dysentery (bloody stools), in which case antimotility agents should be avoided Packages of oral rehydration salts to treat dehydration are available over the counter in the United States (Infalyte, Pedialyte, others) and in many foreign countries
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DuPont HL Azithromycin for the self-treatment of traveler s diarrhea Clin Infect Dis 2007 Feb 1;44(3):347 9 [PMID: 17205439]
B Laboratory Findings
In patients with fever and bloody diarrhea, stool culture is indicated, but in most cases, cultures are reserved for those who do not respond to antibiotics
Common Problems in Infectious Diseases & Antimicrobial Therapy
Hill D R et al The practice of travel medicine: guidelines by the Infectious Disease Society of America Clin Infect Dis 2006 Dec 15;43(12):1499 539 [PMID: 17109284] Thielman NM et al Clinical practice Acute infectious diarrhea N Engl J Med 2004 Jan 1;350(1):38 47 [PMID: 14702426]
CMDT 2008
ANTIMICROBIAL THERAPY SELECTED PRINCIPLES OF ANTIMICROBIAL THERAPY
Specific steps (outlined below) are required when considering antibiotic therapy for patients Drugs within classes, drugs of first choice, and alternative drugs are presented in Tables 30 4, 30 5, 30 6, 30 7, and 30 8
A Etiologic Diagnosis
Based on the organ system involved, the organism causing infection can often be predicted See Tables 30 9 and 30 10
Over the past 10 years, pharmaceutical companies have shifted away from developing and producing antibacterial medications Consequently, few new agents, particularly those active against gram-negative pathogens, are expected The lack of new drugs and increasing bacterial resistance reinforce the need to use these drugs judiciously Antimicrobial drug susceptibility tests may be performed on solid media as disk tests, in broth in tubes, in wells of microdilution plates, or as E-tests (strips with increasing concentration of antibiotic) The latter three methods yield results expressed as MIC (minimal inhibitory concentration), and the broth and microdilution techniques can be modified to give MBC (minimal bactericidal concentration) results In most infections, the MIC is the appropriate in vitro test to guide selection of an antibacterial agent When there appear to be marked discrepancies between susceptibility testing and clinical response, the following possibilities must be considered: 1 Selection of an inappropriate drug, drug dosage, or route of administration 2 Failure to drain a collection of pus or to remove a foreign body 3 Failure of a poorly diffusing drug to reach the site of infection (eg, central nervous system) or to reach intracellular phagocytosed bacteria 4 Superinfection in the course of prolonged chemotherapy 5 Emergence of drug-resistant organisms 6 Participation of two or more microorganisms in the infectious process, of which only one was originally detected and used for drug selection 7 Inadequate host defenses, including immunodeficiencies and diabetes 8 Noninfectious causes, including drug fever, malignancy, and autoimmune disease
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