Clostridium difficile-associated diarrhea after antibiotic treatment for traveler's diarrhea

Bacterial travellers' diarrhoea: A narrative review of literature published over the past 10 years

Travellers' diarrhoea (TD) is the most frequent illness experienced by international travellers to lower-income countries with bacterial agents considered to account for 80-90% of cases. In this review, we summarise evidence published on bacterial TD over the past 10 years, focusing on the epidemiology and aetiology of TD. Diarrhoeagenic Escherichia coli (DEC) continue to be the most commonly implicated bacteria in TD, although Enteropathogenic E. coli (EPEC) and Enteroaggregative E. coli (EAEC) now appear to be predominant where Enterotoxigenic E. coli (ETEC) was previously considered most prevalent globally. Where fluroquinolone resistance had primarily been documented for Campylobacter in Southeast Asia, widespread resistance has been observed in most regions of the world for multiple enteropathogens, including Shigella, Salmonella, ETEC and EAEC. Implementation of novel molecular methods for pathogen detection has led to identification of bacterial pathogens, including Clostridium difficile (with and without the use of prior antibiotics), Arcobacter species and Bacteroides fragilis, as aetiological agents in TD. The widespread resistance to first-line antibiotics in multiple bacterial enteropathogens warrants continued surveillance and re-evaluation of current treatment practices. Further investigations are required to determine the prevalence and geographical distribution of bacterial enteropathogens that have been more recently implicated in TD.

Antibiotic resistance in travellers' diarrhoeal disease, an external perspective

BACKGROUND

There are many recommendations on the use of antibiotics for prophylaxis and treatment of travellers' diarrhoea (TD). As pharmacists with a special interest in antimicrobial stewardship, we examine and offer our perspective on advice that is recommended to travellers in terms of prevention, treatment and management of TD with a focus on antibiotic use and resistance.

METHODS

Publications on TD were identified through PubMed, Google Scholar and Cochrane Library databases searches using search terms 'travellers diarrhoea', 'travellers diarrhoea', 'travellers' diarrhoea' 'guidelines', 'expert opinion', 'expert reviews', 'South Asia' and 'South East Asia' (S and SE Asia), 'antibiotics', 'resistance genes', 'travel advice', 'pharmacists', 'guidelines', 'prevention' and 'treatment'. References of articles were also screened for additional relevant studies.

RESULTS

Whilst most guidelines and expert reviews were in agreement with the restricted use of antibiotics unless there was a clinical need, the literature review identified gaps in research into behaviours of travellers regarding non-compliance with the pre-travel advice provided and the need for in depth training and education for all healthcare professionals in providing 'tailored' advice for travellers going to high-risk destinations.

CONCLUSIONS

Travellers should be made aware of the problems of antimicrobial resistance in their destination and home countries and offered alternative forms of prophylaxis for TD. Strategies for prevention of TD, other than the use of antibiotics, also need to be emphasized. All healthcare professionals involved in giving advice about TD should be familiar with the epidemiology of the condition as this will inform responsible behaviours, risk assessment and management strategies in different geographical areas.

The effectiveness of empirical anti-parasitic treatment in returning travellers with persistent abdominal symptoms

BACKGROUND

Persistent abdominal symptoms (PAS) are common among returning-travellers. In the absence of sensitive tests to identify intestinal parasites, gastrointestinal (GI) symptoms often remain a diagnostic challenge. In this study we examined the effectiveness of empirical anti-parasitic treatment in returning-travellers with PAS despite no positive stool-test.

METHODS

A retrospective study among returning travellers who approached the clinic between the years 2014 and 2016 with GI complaints without a positive stool-test. The empirical treatment included broad-spectrum anti-parasitic agents-oral Tinidazole and Albendazole. A follow-up questionnaire was performed at least 6 months post-treatment.

RESULTS

A total of 102 patients responded the questionnaire-50% women; average age 31.14 (±12.20) years. The average duration of complaints before treatment was 16.52 (±30.06) months. Common GI symptoms included abdominal pain (83.3%) and diarrhoea (78.4%); 67.6% of the patients complained of extreme fatigue. Overall, 69% of the patients reported an improvement in GI symptoms, 37% of them reported full recovery within a few weeks post-treatment. Furthermore, there was an improvement in the energy level and general well-being in 68% and 70% of the patients, respectively. Only 33% of the patients reported minor side effects related to the treatment.

CONCLUSIONS

The improvement in GI symptoms, energy level and general well-being shortly after anti-parasitic treatment justifies this empirical approach in returning-travellers with PAS despite negative stool-tests. The association between fatigue and PAS post-travel and the improvement in both as a response to treatment defines fatigue as part of a new syndrome-'Post-travel fatigue and abdominal symptoms'.

Management of Acute Diarrheal Illness During Deployment: A Deployment Health Guideline and Expert Panel Report

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.

Clostridium difficile infection in returning travellers

Background

There is increasing recognition of the contribution of community-acquired cases to the global burden of Clostridium difficile infection (CDI). The epidemiology of CDI among international travellers is poorly understood, and factors associated with international travel, such as antibiotic use and changes in gut microbiota, could potentially put travellers at higher risk.

Methods

We summarized demographic, travel-associated and geographic characteristics of travellers with CDI in the GeoSentinel database from 1997 to 2015. We also surveyed GeoSentinel sites to compare various testing indications, approaches, and diagnostic modalities.

Results

We identified 260 GeoSentinel records, including 187 that satisfied criteria for analysis (confirmed cases in non-immigrant travellers aged >2 years, seen <12 weeks post-travel). CDI was reported in all age groups and in travellers to all world regions; the largest proportions of cases having destinations in Asia (31%), Central/South America or the Caribbean (30%) and Africa (24%). Our site survey revealed substantial heterogeneity of testing approaches between sites; the most commonly used test was the C. difficile toxin gene PCR.

Conclusions

CDI is encountered in returning international travellers, although there is considerable variability in testing practices. These data underscore the importance of awareness of C. difficile as a potential cause of travel-associated diarrhoea.

Epidemiology of travellers' diarrhea

BACKGROUND

Travellers' diarrhea (TD) continues to be the most frequent health problem in travellers with destinations in lower income parts of the world as compared with where they reside, even if that risk has slightly decreased.

METHODS

A systematic review was published 18 months ago; now PubMed was searched for more recent publications relating to travel, diarrhea, epidemiology, incidence, risk.

RESULTS

A trend to decreasing incidence rates have been noted in this as compared with the last century, but TD remains frequent. The clinical picture varies from a trivial ailment to severe with subsequent hospitalization. Of great concern are long-term sequelae, particularly post-infectious irritable bowel syndrome. The most important risk factors are the destination and duration of exposure among the environmental factors, whereas the age is the most relevant host factor.

CONCLUSIONS

Even if improved hygienic conditions in low-income countries often visited by travellers have resulted in slightly diminished incidence rates of TD, this remains a frequent health problem. Visitors to such destinations must be informed about that health risk and it is beneficial to equip them with instructions and a travel kit to enable them to some extent self-manage TD occurring abroad.

Use of antimicrobial agents for treatment and prevention of travellers' diarrhoea in the face of enhanced risk of transient fecal carriage of multi-drug resistant enterobacteriaceae: setting the stage for consensus recommendations

BACKGROUND

The recommendation that antibiotics should be used for routine therapy of travellers' diarrhoea is being reconsidered in view of growing evidence that the therapy may lead to intestinal carriage of multi-drug resistant (MDR) colonic microbiota. This review attempts to put the issues of therapy and MDR acquisition in perspective to help in the establishment of therapeutic recommendations for travellers' diarrhoea.

METHODS

The existing literature showing the risk and consequences of acquisition of MDR microbiota in antibiotic-treated travellers was reviewed. Issues important to the development of firm evidence-based recommendations for antibiotics use for treatment and prevention of travellers' diarrhoea were researched.

RESULTS

Six areas of research needed to allow the development of evidence-based recommendations for antibiotic-treatment and -prevention of travellers' diarrhoea were identified.

CONCLUSIONS

Increasing worldwide occurrence of antibiotic resistance should alert public health officials of the importance of encouraging local antibiotic stewardship guidelines. Six areas to research are identified in this review to allow the development of evidence-based recommendations for use of antibiotics for treatment and selective prevention of travellers' diarrhoea. An interdisciplinary ISTM Consensus group will consider the data available and develop current recommendations for therapy and chemoprevention of travellers' diarrhoea considering groups who would benefit the most from antimicrobials while recognizing the hazards associated with broad use of these drugs. With interim recommendations and ultimately evidence-based recommendations, guidelines can be developed for management of travellers' diarrhoea considering populations and destinations.

Use of antimicrobial agents for treatment and prevention of travellers' diarrhoea in the face of enhanced risk of transient fecal carriage of multi-drug resistant enterobacteriaceae: setting the stage for consensus recommendations

BACKGROUND

The recommendation that antibiotics should be used for routine therapy of travellers' diarrhoea is being reconsidered in view of growing evidence that the therapy may lead to intestinal carriage of multi-drug resistant (MDR) colonic microbiota. This review attempts to put the issues of therapy and MDR acquisition in perspective to help in the establishment of therapeutic recommendations for travellers' diarrhoea.

METHODS

The existing literature showing the risk and consequences of acquisition of MDR microbiota in antibiotic-treated travellers was reviewed. Issues important to the development of firm evidence-based recommendations for antibiotics use for treatment and prevention of travellers' diarrhoea were researched.

RESULTS

Six areas of research needed to allow the development of evidence-based recommendations for antibiotic-treatment and -prevention of travellers' diarrhoea were identified.

CONCLUSIONS

Increasing worldwide occurrence of antibiotic resistance should alert public health officials of the importance of encouraging local antibiotic stewardship guidelines. Six areas to research are identified in this review to allow the development of evidence-based recommendations for use of antibiotics for treatment and selective prevention of travellers' diarrhoea. An interdisciplinary ISTM Consensus group will consider the data available and develop current recommendations for therapy and chemoprevention of travellers' diarrhoea considering groups who would benefit the most from antimicrobials while recognizing the hazards associated with broad use of these drugs. With interim recommendations and ultimately evidence-based recommendations, guidelines can be developed for management of travellers' diarrhoea considering populations and destinations.

ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults

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.

Traveler's Diarrhea

Travelers' diarrhea (TD) is the most important health issue among international travelers. In high risk areas, 50-90% of travelers may experience an episode of TD. The risk of acquiring TD is influenced by factors such as the destination, duration of stay, standard of accommodation, type of travel, age of the traveler, and also by individual risk factors. Most cases of TD are caused by bacteria; treatment for TD are loperamide and antibiotics. Preventive strategies such as hygiene measures have limited impact. Prophylactic intake of antibiotics or vaccines to prevent from TD can be considered in special situations.

Clostridium difficile Infection in travelers--a neglected pathogen?

BACKGROUND

Until recently, Clostridium difficile infection (CDI) has been mostly diagnosed in hospitalized elderly patients treated with antibacterial agents. The epidemiology of C difficile is changing as the ribotype 027 strain is spreading worldwide, and more infections are diagnosed in patients residing in the community. Although only few data about the epidemiology of CDI in developing countries are available, a number of reports seem to indicate that the incidence of CDI may be high in some such countries. Transmission of CDI may be more common in hospitals that lack the resources for efficient infection control programs. Theoretically, travelers to low-income countries may be exposed to C difficile both in the community and within hospitals.

METHODS

Data for this article were identified by searches of PubMed and MEDLINE, and references from relevant articles using the search terms "clostridium" and "travel." Abstracts were included when related to previously published work.

RESULTS AND CONCLUSIONS

A total of 48 cases of travelers with CDI were located. CDI among travelers was more commonly acquired in low- and medium-income countries, although 20% of all reported cases occurred in travelers returning from high-income countries. All travelers with CDI for whom a detailed history was available acquired the infection in the community. CDI in travelers occurred in relatively young patients and was frequently associated with the empiric use of antibacterial agents, notably fluoroquinolones. A sizable minority of travelers with CDI had no exposure to antibacterial agents at all. The incidence of travel-related CDI is unknown, but may be higher than previously suspected. A prospective study among travelers with unexplained acute or chronic diarrhea is warranted.

Advances in the treatment of travelers' diarrhea

Diarrhea is the most common complaint reported by travelers from industrialized countries visiting developing nations. High-risk areas for travelers' diarrhea (TD) include South Asia, Sub-Saharan Africa, and Latin America, while moderate-risk areas include Southeast Asia, Middle East, Oceania and the Caribbean. Bacterial pathogens are the major cause of TD. Recent advances in the therapy for diarrhea include a better understanding of the potential benefit of symptomatic and antimicrobial therapy. The mainstay of treatment includes antibacterial therapy with one of three drugs, a fluoroquinolone, rifaximin, or azithromycin. Probiotics have been used in preliminary studies for both treatment and prevention of TD, but more studies are needed with these biologic agents. The aim of this review is to identify the recent advances in the therapy of TD and to provide recommendations for treatment during international travel.

Management of the returning traveler with diarrhea

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.

First Australian isolation of epidemic Clostridium difficile PCR ribotype 027

We report the first isolation in Australia of a hypervirulent epidemic strain of Clostridium difficile, PCR ribotype 027. It was isolated from a 43-year-old woman with a permanent ileostomy, who appears to have been infected while travelling in the United States. The isolate was positive for toxin A, toxin B and binary toxin, and resistant to fluoroquinolone antimicrobials, and had characteristic deletions in the tcdC gene. All diagnostic laboratories and health care facilities in Australia should now be on high alert for this organism.

Systematic review: the epidemiology and clinical features of travellers' diarrhoea

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.