Chapter 3Infectious Diseases Related To Travel
Melissa Viray, Michael Lynch
Infection is caused by gram-negative, spiral-shaped microaerophilic bacteria of the family Campylobacteraceae. Most infections are caused by Campylobacter jejuni; other species, including C. coli, also cause infection. C. jejuni and C. coli are carried normally in the intestinal tracts of many domestic and wild animals.
MODE OF TRANSMISSION
The major modes of transmission include eating contaminated foods (especially undercooked chicken and foods contaminated by raw chicken), drinking contaminated water or raw (unpasteurized) milk, or having contact with animals, particularly farm animals such as cattle and poultry, as well as cats and dogs.
Campylobacter is a leading cause of bacterial diarrheal disease worldwide; in the United States, it is estimated to affect 2.4 million people every year. Campylobacteriosis is a common cause of travelers’ diarrhea. The percentage of bacterial travelers’ diarrhea caused by Campylobacter ranges from 1%–2% in Mexico to 28% in Thailand. The infectious dose is thought to be small, typically fewer than 500 organisms.
The geographic distribution of cases is worldwide; risk for infection is higher in the developing world, especially in areas with poor restaurant hygiene and inadequate sanitation.
Incubation period is typically 2–4 days. Campylobacteriosis is characterized by diarrhea (frequently bloody), abdominal pain, fever, and occasionally, nausea and vomiting. More severe presentations can occur, including bloodstream infection and disease mimicking acute appendicitis or ulcerative colitis. Campylobacter infection can trigger Guillain-Barré syndrome. Additional information can be found on the CDC website (www.cdc.gov/nczved/divisions/dfbmd/diseases/campylobacter).
Diagnosis is based on isolation of the organism from stools by using selective media and reduced oxygen tension. Most laboratories also combine this with incubation at 42°C (107.6°F). Visualization of motile and curved, spiral, or S-shaped rods by stool phase-contrast or darkfield microscopy can provide rapid presumptive evidence for Campylobacter enteritis.
The disease is generally self-limited and may last up to a week. Antibiotic therapy decreases the duration of symptoms if administered early in the course of disease. Because it is generally not possible to distinguish campylobacteriosis from other causes of travelers’ diarrhea without a diagnostic test, the use of empiric antibiotics in travelers should follow the guidelines for travelers’ diarrhea.
Rates of antibiotic resistance have been on the rise in the past 20 years, in particular for fluoroquinolones; travel abroad has been associated with infection with resistant Campylobacter. Clinicians should have a high degree of suspicion for resistant infection in returning travelers who may have failed empiric fluoroquinolone treatment. Documented fluoroquinolone resistance has been highest among travelers to Thailand. When fluoroquinolone resistance is proven or suspected, azithromycin is usually the next choice of treatment.
PREVENTIVE MEASURES FOR TRAVELERS
No vaccine is available. Antibiotic prophylaxis, as used for travelers’ diarrhea, is likely to be effective, although antibiotic prophylaxis is not routinely recommended. Preventive measures are aimed at avoiding foods at high risk for contamination and taking safe water precautions while traveling (see Chapter 2, Food and Water Precautions).
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- Tribble DR, Sanders JW, Pang LW, Mason C, Pitarangsi C, Baqar S, et al. Traveler’s diarrhea in Thailand: randomized, double-blind trial comparing single-dose and 3-day azithromycin-based regimens with a 3-day levofloxacin regimen. Clin Infect Dis. 2007 Feb 1;44(3):338–46.
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