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Manthey CF, Epple HJ, Keller KM, Lübbert C, Posovszky C, Ramharter M, Reuken P, Suerbaum S, Vehreschild M, Weinke T, Addo MM, Stallmach A, Lohse AW. S2k-Leitlinie Gastrointestinale Infektionen der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1090-1149. [PMID: 38976986 DOI: 10.1055/a-2240-1428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Affiliation(s)
- Carolin F Manthey
- I. Medizinische Klinik und Poliklinik - Schwerpunkt Gastroenterologie; Sektionen Infektions- und Tropenmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
- Gemeinschaftspraxis Innere Medizin Witten, Witten, Deutschland
| | - Hans-Jörg Epple
- Antibiotic Stewardship, Vorstand Krankenversorgung, Universitätsmedizin Berlin, Berlin, Deutschland
| | - Klaus-Michael Keller
- Klinik für Kinder- und Jugendmedizin, Helios Dr. Horst Schmidt Kliniken, Klinik für Kinder- und Jugendmedizin, Wiesbaden, Deutschland
| | - Christoph Lübbert
- Bereich Infektiologie und Tropenmedizin, Medizinische Klinik I (Hämatologie, Zelltherapie, Infektiologie und Hämostaseologie), Universitätsklinikum Leipzig, Leipzig, Deutschland
| | | | - Michael Ramharter
- I. Medizinische Klinik und Poliklinik - Schwerpunkt Gastroenterologie; Sektionen Infektions- und Tropenmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Philipp Reuken
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie, Infektiologie, Zentrale Endoskopie), Universitätsklinikum Jena, Jena, Deutschland
| | - Sebastian Suerbaum
- Universität München, Max von Pettenkofer-Institut für Hygiene und Medizinische Mikrobiologie, München, Deutschland
| | - Maria Vehreschild
- Medizinische Klinik II, Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Thomas Weinke
- Klinik für Gastroenterologie und Infektiologie, Klinikum Ernst von Bergmann, Potsdam, Deutschland
| | - Marylyn M Addo
- I. Medizinische Klinik und Poliklinik - Schwerpunkt Gastroenterologie; Sektionen Infektions- und Tropenmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
- Institut für Infektionsforschung und Impfstoffentwicklung Sektion Infektiologie, I. Med. Klinik, Zentrum für Innere Medizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Andreas Stallmach
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie, Infektiologie, Zentrale Endoskopie), Universitätsklinikum Jena, Jena, Deutschland
| | - Ansgar W Lohse
- I. Medizinische Klinik und Poliklinik - Schwerpunkt Gastroenterologie; Sektionen Infektions- und Tropenmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
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Potin M, Carron PN, Genton B. Injuries and medical emergencies among international travellers. J Travel Med 2024; 31:taad088. [PMID: 37405992 DOI: 10.1093/jtm/taad088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 06/07/2023] [Accepted: 06/12/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Tropical infectious diseases and vaccine-preventable emergencies are the mainstay of pre-travel consultations. However, non-communicable diseases, injuries and accidents that occur during travel are not emphasized enough in these settings. METHODS We performed a narrative review based on a literature search of PubMed, Google Scholar, UpToDate, DynaMed and LiSSa and on reference textbooks and medical journals dedicated to travel, emergency and wilderness medicine. Relevant secondary references were extracted. We also aimed to discuss newer or neglected issues, such as medical tourism, Coronavirus Disease 2019, exacerbations of co-morbidities associated with international travel, insurance coverage, health care seeking abroad, medical evacuation or repatriation and tips for different types of travellers' emergency medical kits (personal, group, physician handled). RESULTS All sources reviewed led to the selection of >170 references. Among epidemiological data on morbidity and deaths while abroad, only retrospective data are available. Deaths are estimated to occur in 1 in 100 000 travellers, with 40% caused by trauma and 60% by diseases, and <3% linked to infectious diseases. Trauma and other injuries acquired during travel, such as traffic accidents and drowning, can be reduced by up to 85% with simple preventive recommendations such as avoiding simultaneous alcohol intake. In-flight emergencies occur on 1 in 604 flights on average. Thrombosis risk is two to three times greater for travellers than for non-travellers. Fever during or after travel can occur in 2-4% of travellers, but in up to 25-30% in tertiary centres. Traveller's diarrhoea, although rarely severe, is the most common disease associated with travel. Autochthonous emergencies (acute appendicitis, ectopic pregnancy, dental abscess) can also occur. CONCLUSIONS Pre-travel medicine encounters must include the topic of injuries and medical emergencies, such as the risk-taking behaviours and foster better planning in a comprehensive approach along with vaccines and infectious diseases advices.
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Affiliation(s)
- Mathieu Potin
- ISTM CTH (Certificate of Travel Health), Chemin des Croix-Rouges 12, Lausanne CH-1007, Switzerland
| | - Pierre-Nicolas Carron
- Emergency Department, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, Lausanne CH-1011, Switzerland
| | - Blaise Genton
- Policlinic of Tropical, Travel Medicine and Vaccination, Centre for Primary Care and Public Health, Unisanté, University of Lausanne, Rue du Bugnon 44, Lausanne CH-1011, Switzerland
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Terefe L, Nardos A, Debella A, Dereje B, Arega M, Abebe AG, Gemechu W, Woldekidan S. Antidiarrheal Activities of the Methanol Leaf Extracts of Olinia rochetiana (Oliniaceae) Against Castor Oil-Induced Diarrhea in Mice. J Exp Pharmacol 2023; 15:485-495. [PMID: 38026232 PMCID: PMC10676088 DOI: 10.2147/jep.s441555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 11/17/2023] [Indexed: 12/01/2023] Open
Abstract
Background Olinia rochetiana has been used traditionally to cure diarrheal disease. Therefore, this study aimed to investigate the acute toxicity and antidiarrheal effect of O. rochetiana leaf extracts. Methods Cold maceration was used to extract plant leaf powder with 80% methanol. The extract's antidiarrheal action was tested against a castor oil-induced diarrheal model, a charcoal meal test, and enteropooling tests at doses of 100, 200, and 400 mg/kg. Negative controls received the vehicle at 10 mL/kg, while positive controls received loperamide at 3 mg/kg. Results From the study, no apparent toxicity was observed when a single dose of 2000 mg/kg was administered. In the castor oil-induced model, the extract delayed the onset of diarrhea, reduced stool frequency, and decreased wet feces weight and number in a dose-dependent manner at 200 mg/kg (p < 0.05) and 400 mg/kg (p < 0.01). The percent reduction in moist feces at 100, 200, and 400 mg/kg was 54.2, 23.97, and 18.26%, respectively, indicating a significant dose-dependent decrease. In a charcoal meal test, the extracts at 200 and 400 mg/kg revealed a peristaltic index of 65 and 46%, respectively, with considerable inhibition of charcoal transport at 23 and 39%. The weight and volume of intestinal contents dropped significantly at a dose of 400 mg/kg (p < 0.01), which is 0.43 mg/kg, in the enteropooling test when compared with the tested dose. The computed in vivo antidiarrheal index revealed diarrheal inhibition values of 46.06 and 71.06% at 200 and 400 mg/kg, respectively. Conclusion In the current investigation, O. rochetiana showed significant antidiarrheal activity with no symptoms of toxicity in mice.
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Affiliation(s)
- Lidet Terefe
- Department of Pharmacology, School of Pharmacy, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Aschalew Nardos
- Department of Pharmacology, School of Pharmacy, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Asfaw Debella
- Department of Traditional and Modern Medicine Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Beyene Dereje
- Department of Pharmacology, School of Medicine, College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia
| | - Melese Arega
- Department of Pharmacy, Pawi Health Sciences College, Pawi, Ethiopia
| | - Abiy Gelagle Abebe
- Department of Traditional and Modern Medicine Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Worku Gemechu
- Department of Traditional and Modern Medicine Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Samuel Woldekidan
- Department of Traditional and Modern Medicine Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
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DuPont HL, Almenoff JS, Jamindar MS, Bortey E, Steffen R. Development of a new travellers' diarrhoea clinical severity classification and its utility in confirming rifamycin-SV efficacy. J Travel Med 2023; 30:taad043. [PMID: 37052453 PMCID: PMC10628770 DOI: 10.1093/jtm/taad043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND travellers' diarrhoea (TD) is frequently reported with incidence up to 40% in high-risk destinations. Previous studies showed that the number of loose stools alone is inadequate to holistically predict the severity of TD. To improve the prediction of prognosis and to optimize treatments, a simple risk-based clinical severity classification has been developed. METHODS pooled baseline data of signs and symptoms and number of loose stools from 1098 subjects enrolled in two double-blind Phase 3 trials of rifamycin-SV were analyzed with correlation, multiple correspondence analyses, prognostic factor criteria, and Contal and O'Quigley method to generate a TD severity classification (mild, moderate and severe). The relative importance of this classification on resolution of TD was assessed by Cox proportional model hazard model on the time to last unformed stool (TLUS). RESULTS the analysis showed that TLUS were longer for the severe [hazard ratio (HR) 0.24; P < 0.001; n = 173] and moderate (HR 0.54; P = 0.0272; n = 912) vs mild. Additionally, when the treatment assigned in the studies was investigated in the severity classification, the results yielded that rifamycin-SV significantly shortened TLUS vs placebo for all subjects (HR 1.9; P = 0.0006), severe (HR 5.9; P = 0.0232) and moderate (HR 1.7; P = 0.0078) groups and was as equally efficacious as ciprofloxacin for all subjects, moderate and severe groups (HRs: 0.962, 0.9, 1.2; all P = NS, respectively). When reassessed by this classification, rifamycin-SV showed consistent efficacy with the Phase 3 studies. CONCLUSIONS this newly developed TD clinical severity classification demonstrated strong prognostic value and clinical utility by combining patients' multiple signs and symptoms of enteric infection and number of loose stools to provide a holistic assessment of TD. By expanding on the current classification by incorporating patient reported outcomes in addition to TLUS, a classification like the one developed, may help optimize patient selection for future clinical studies.
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Affiliation(s)
- Herbert L DuPont
- Internal Medicine, University of Texas School of Public Health, Houston, TX 77030, USA
| | - June S Almenoff
- Department of Medical Affairs, Redhill Biopharma Inc., Raleigh, NC 27617, USA
| | - Mansi S Jamindar
- Department of Medical Affairs, Redhill Biopharma Inc., Raleigh, NC 27617, USA
| | - Enoch Bortey
- Pharmaceutical Development Strategies LLC, Chapel Hill, NC 27517, USA
| | - Robert Steffen
- Department of Epidemiology, University of Zurich, 8001 Zurich, Switzerland
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España-Cueto S, Oliveira-Souto I, Salvador F, Goterris L, Treviño B, Sánchez-Montalvá A, Serre-Delcor N, Sulleiro E, Rodríguez V, Aznar ML, Bosch-Nicolau P, Espinosa-Pereiro J, Pou D, Molina I. Post-infectious irritable bowel syndrome following a diagnosis of traveller's diarrhoea: a comprehensive characterization of clinical and laboratory parameters. J Travel Med 2023; 30:taad030. [PMID: 36881659 DOI: 10.1093/jtm/taad030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Prolonged or recurrent gastrointestinal symptoms may persist after acute traveller's diarrhoea (TD), even after adequate treatment of the primary cause. This study aims to describe the epidemiological, clinical and microbiological characteristics of patients with post-infectious irritable bowel syndrome (PI-IBS) after returning from tropical or subtropical areas. METHODS We conducted a retrospective study of patients presenting between 2009 and 2018 at the International Health referral centre in Barcelona with persistent gastrointestinal symptoms following a diagnosis of TD. PI-IBS was defined as the presence of persistent or recurrent gastrointestinal manifestations for at least 6 months after the diagnosis of TD, a negative stool culture for bacterial pathogens and a negative ova and parasite exam after targeted treatment. Epidemiological, clinical and microbiological variables were collected. RESULTS We identified 669 travellers with a diagnosis of TD. Sixty-eight (10.2%) of these travellers, mean age 33 years and 36 (52.9%) women, developed PI-IBS. The most frequently visited geographical areas were Latin America (29.4%) and the Middle East (17.6%), with a median trip duration of 30 days (IQR 14-96). A microbiological diagnosis of TD was made in 32 of these 68 (47%) patients, 24 (75%) of whom had a parasitic infection, Giardia duodenalis being the most commonly detected parasite (n = 20, 83.3%). The symptoms persisted for a mean of 15 months after diagnosis and treatment of TD. The multivariate analysis revealed that parasitic infections were independent risk factors for PI-IBS (OR 3.0, 95%CI 1.2-7.8). Pre-travel counselling reduced the risk of PI-IBS (OR 0.4, 95%CI 0.2-0.9). CONCLUSIONS In our cohort, almost 10% of patients with travellers' diarrhoea developed persistent symptoms compatible with PI-IBS. Parasitic infections, mainly giardiasis, seem to be associated with PI-IBS.
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Affiliation(s)
- Sergio España-Cueto
- International Health Unit Vall d'Hebron-Drassanes, Infectious Diseases Department, Vall d'Hebron University Hospital, PROSICS Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain
- Infectious Diseases Department, Germans Trias i Pujol University Hospital, Badalona, Spain
- The Fight Infections Foundation, Badalona, Spain
| | - Inés Oliveira-Souto
- International Health Unit Vall d'Hebron-Drassanes, Infectious Diseases Department, Vall d'Hebron University Hospital, PROSICS Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Fernando Salvador
- International Health Unit Vall d'Hebron-Drassanes, Infectious Diseases Department, Vall d'Hebron University Hospital, PROSICS Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Lidia Goterris
- Department of Microbiology, Vall d'Hebron University Hospital and PROSICS, Barcelona, Spain
| | - Begoña Treviño
- International Health Unit Vall d'Hebron-Drassanes, Infectious Diseases Department, Vall d'Hebron University Hospital, PROSICS Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Adrián Sánchez-Montalvá
- International Health Unit Vall d'Hebron-Drassanes, Infectious Diseases Department, Vall d'Hebron University Hospital, PROSICS Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Núria Serre-Delcor
- International Health Unit Vall d'Hebron-Drassanes, Infectious Diseases Department, Vall d'Hebron University Hospital, PROSICS Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Elena Sulleiro
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Microbiology, Vall d'Hebron University Hospital and PROSICS, Barcelona, Spain
| | - Virginia Rodríguez
- Department of Microbiology, Vall d'Hebron University Hospital and PROSICS, Barcelona, Spain
| | - Maria Luisa Aznar
- International Health Unit Vall d'Hebron-Drassanes, Infectious Diseases Department, Vall d'Hebron University Hospital, PROSICS Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Pau Bosch-Nicolau
- International Health Unit Vall d'Hebron-Drassanes, Infectious Diseases Department, Vall d'Hebron University Hospital, PROSICS Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Juan Espinosa-Pereiro
- International Health Unit Vall d'Hebron-Drassanes, Infectious Diseases Department, Vall d'Hebron University Hospital, PROSICS Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Diana Pou
- International Health Unit Vall d'Hebron-Drassanes, Infectious Diseases Department, Vall d'Hebron University Hospital, PROSICS Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Israel Molina
- International Health Unit Vall d'Hebron-Drassanes, Infectious Diseases Department, Vall d'Hebron University Hospital, PROSICS Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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Maier N, Grahek SL, Halpern J, Restrepo S, Troncoso F, Shimko J, Torres O, Belkind-Gerson J, Sack DA, Svennerholm AM, Gustafsson B, Sjöstrand B, Carlin N, Bourgeois AL, Porter CK. Efficacy of an Enterotoxigenic Escherichia coli (ETEC) Vaccine on the Incidence and Severity of Traveler's Diarrhea (TD): Evaluation of Alternative Endpoints and a TD Severity Score. Microorganisms 2023; 11:2414. [PMID: 37894071 PMCID: PMC10609384 DOI: 10.3390/microorganisms11102414] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/15/2023] [Accepted: 09/20/2023] [Indexed: 10/29/2023] Open
Abstract
The efficacy of an Oral Whole Cell ETEC Vaccine (OEV) against Travelers' Diarrhea (TD) was reexamined using novel outcome and immunologic measures. More specifically, a recently developed disease severity score and alternative clinical endpoints were evaluated as part of an initial validation effort to access the efficacy of a vaccine intervention for the first time in travelers to an ETEC endemic area. A randomized, double-blind, placebo-controlled trial followed travelers to Guatemala or Mexico up to 28 days after arrival in the country following vaccination (two doses two weeks apart) with an ETEC vaccine. Fecal samples were collected upon arrival, departure, and during TD for pathogen identification. Serum was collected in a subset of subjects to determine IgA cholera toxin B subunit (CTB) antibody titers upon their arrival in the country. The ETEC vaccine's efficacy, utilizing a TD severity score and other alternative endpoints, including the relationship between antibody levels and TD risk, was assessed and compared to the per-protocol primary efficacy endpoint. A total of 1435 subjects completed 7-28 days of follow-up and had available data. Vaccine efficacy was higher against more severe (≥5 unformed stools/24 h) ETEC-attributable TD and when accounting for immunologic take (PE ≥ 50%; p < 0.05). The vaccine protected against less severe (3 and 4 unformed stools/24 h) ETEC-attributable TD when accounting for symptom severity or change in activity (PE = 76.3%, p = 0.01). Immunologic take of the vaccine was associated with a reduced risk of infection with ETEC and other enteric pathogens, and with lower TD severity. Clear efficacy was observed among vaccinees with a TD score of ≥4 or ≥5, regardless of immunologic take (PE = 72.0% and 79.0%, respectively, p ≤ 0.03). The vaccine reduced the incidence and severity of ETEC, and this warrants accelerated evaluation of the improved formulation (designated ETVAX), currently undergoing advanced field testing. Subjects with serum IgA titers to CTB had a lower risk of infection with ETEC and Campylobacter jejuni/coli. Furthermore, the TD severity score provided a more robust descriptor of disease severity and should be included as an endpoint in future studies.
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Affiliation(s)
| | - Shannon L. Grahek
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; (S.L.G.); (J.H.); (S.R.); (F.T.); (J.S.); (D.A.S.)
| | - Jane Halpern
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; (S.L.G.); (J.H.); (S.R.); (F.T.); (J.S.); (D.A.S.)
| | - Suzanne Restrepo
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; (S.L.G.); (J.H.); (S.R.); (F.T.); (J.S.); (D.A.S.)
| | - Felipe Troncoso
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; (S.L.G.); (J.H.); (S.R.); (F.T.); (J.S.); (D.A.S.)
| | - Janet Shimko
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; (S.L.G.); (J.H.); (S.R.); (F.T.); (J.S.); (D.A.S.)
| | - Olga Torres
- Laboratorio Diagnostico Molecular, Guatemala City 01009, Guatemala;
| | | | - David A. Sack
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; (S.L.G.); (J.H.); (S.R.); (F.T.); (J.S.); (D.A.S.)
| | - Ann-Mari Svennerholm
- Department of Microbiology and Immunology, University of Gothenburg, 405 30 Gothenburg, Sweden;
| | - Björn Gustafsson
- Scandinavian Biopharma Holding AB, 171 48 Stockholm, Sweden (B.S.); (N.C.)
| | - Björn Sjöstrand
- Scandinavian Biopharma Holding AB, 171 48 Stockholm, Sweden (B.S.); (N.C.)
| | - Nils Carlin
- Scandinavian Biopharma Holding AB, 171 48 Stockholm, Sweden (B.S.); (N.C.)
| | | | - Chad K. Porter
- Naval Medical Research Command, Silver Spring, MD 20910, USA;
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Bansal SB, Ramasubramanian V, Prasad N, Saraf N, Soman R, Makharia G, Varughese S, Sahay M, Deswal V, Jeloka T, Gang S, Sharma A, Rupali P, Shah DS, Jha V, Kotton CN. South Asian Transplant Infectious Disease Guidelines for Solid Organ Transplant Candidates, Recipients, and Donors. Transplantation 2023; 107:1910-1934. [PMID: 36749281 DOI: 10.1097/tp.0000000000004521] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
These guidelines discuss the epidemiology, screening, diagnosis, posttransplant prophylaxis, monitoring, and management of endemic infections in solid organ transplant (SOT) candidates, recipients, and donors in South Asia. The guidelines also provide recommendations for SOT recipients traveling to this region. These guidelines are based on literature review and expert opinion by transplant physicians, surgeons, and infectious diseases specialists, mostly from South Asian countries (India, Pakistan, Bangladesh, Nepal, and Sri Lanka) as well as transplant experts from other countries. These guidelines cover relevant endemic bacterial infections (tuberculosis, leptospirosis, melioidosis, typhoid, scrub typhus), viral infections (hepatitis A, B, C, D, and E; rabies; and the arboviruses including dengue, chikungunya, Zika, Japanese encephalitis), endemic fungal infections (mucormycosis, histoplasmosis, talaromycosis, sporotrichosis), and endemic parasitic infections (malaria, leishmaniasis, toxoplasmosis, cryptosporidiosis, strongyloidiasis, and filariasis) as well as travelers' diarrhea and vaccination for SOT candidates and recipients including travelers visiting this region. These guidelines are intended to be an overview of each topic; more detailed reviews are being published as a special supplement in the Indian Journal of Transplantation .
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Affiliation(s)
- Shyam Bihari Bansal
- Department of Nephrology and Kidney Transplantation, Medanta Institute of Kidney and Urology Medanta-Medicity, Gurgaon, India
| | | | - Narayan Prasad
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Neeraj Saraf
- Department of Hepatology, Medanta, Medicity, Gurgaon, India
| | - Rajeev Soman
- Department of Infectious Diseases, Jupiter Hospital, Pune, India
| | - Govind Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Santosh Varughese
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Manisha Sahay
- Department of Nephrology, Osmania Medical College, and Hospital, Hyderabad, India
| | - Vikas Deswal
- Department of Infectious Diseases, Medanta, Medicity, Gurgaon, India
| | - Tarun Jeloka
- Department of Infectious Diseases, Jupiter Hospital, Pune, India
| | - Sishir Gang
- Department of Nephrology, Muljibhai Patel Urological Hospital, Nadiad, Gujrat, India
| | - Ashish Sharma
- Department of Renal Transplant Surgery, PGIMER, Chandigarh, India
| | - Priscilla Rupali
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Dibya Singh Shah
- Department of Nephrology and Transplant Medicine, Institute of Medicine, Tribhuvan University of Teaching hospital, Kathmandu, Nepal
| | | | - Camille Nelson Kotton
- Transplant and Immunocompromised Host Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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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] [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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9
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Muzembo BA, Kitahara K, Mitra D, Ohno A, Khatiwada J, Dutta S, Miyoshi SI. Shigellosis in Southeast Asia: A systematic review and meta-analysis. Travel Med Infect Dis 2023; 52:102554. [PMID: 36792021 DOI: 10.1016/j.tmaid.2023.102554] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 01/20/2023] [Accepted: 02/10/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Southeast Asia is attractive for tourism. Unfortunately, travelers to this region are at risk of becoming infected with Shigella. We conducted a meta-analysis to provide updates on Shigella prevalence in Southeast Asia, along with their serogroups and serotypes. METHODS We conducted a systematic search using PubMed, EMBASE, and Web of Science for peer-reviewed studies from 2000 to November 2022. We selected studies that detected Shigella in stools by culture or polymerase chain reaction (PCR). Two reviewers extracted the data using a standardized form and performed quality assessments using the Joanna Briggs Institute checklist. The random effects model was used to estimate the pooled prevalence of Shigella. RESULTS During our search, we identified 4376 studies. 29 studies (from six Southeast Asian countries) were included in the systematic review, 21 each in the meta-analysis of the prevalence of Shigella (Sample size: 109545) and the prevalence of Shigella serogroups. The pooled prevalence of Shigella was 4% (95% CI: 4-5%) among diarrhea cases. Shigella sonnei was the most abundant serogroup in Thailand (74%) and Vietnam (57%), whereas Shigella flexneri was dominant in Indonesia (72%) and Cambodia (71%). Shigella dysenteriae and Shigella boydii were uncommon (pooled prevalence of 1% each). The pooled prevalence of Shigella was 5% (95% CI: 4-6%) in children aged <5 years. The pooled prevalence showed a decreasing trend comparing data collected between 2000-2013 (5%; 95% CI: 4-6%) and between 2014-2022 (3%; 95% CI: 2-4%). Shigella prevalence was 6% in studies that included participants with mixed pathogens versus 3% in those without. Shigella flexneri serotype 2a was the most frequently isolated (33%), followed by 3a (21%), 1b (10%), 2b (3%), and 6 (3%). CONCLUSIONS This study provides compelling evidence for the development of effective Shigella vaccines for residents of endemic regions and travellers to these areas.
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Affiliation(s)
- Basilua Andre Muzembo
- Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan.
| | - Kei Kitahara
- Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan; Collaborative Research Centre of Okayama University for Infectious Diseases in India at ICMR-NICED, Kolkata, India
| | - Debmalya Mitra
- Collaborative Research Centre of Okayama University for Infectious Diseases in India at ICMR-NICED, Kolkata, India
| | - Ayumu Ohno
- Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan; Collaborative Research Centre of Okayama University for Infectious Diseases in India at ICMR-NICED, Kolkata, India
| | | | - Shanta Dutta
- Division of Bacteriology, ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Shin-Ichi Miyoshi
- Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
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10
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Chen LH, Connor BA. Is standby therapy for Covid-19 a practical option for travellers? J Travel Med 2022; 29:taac111. [PMID: 36263880 PMCID: PMC9619438 DOI: 10.1093/jtm/taac111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022]
Abstract
International travel has resumed while the risk of SARS-CoV-2 persists, leading to consideration of medications that can treat or prevent Covid-19 when travellers become ill abroad. Nirmatrelvir-ritonavir, molnupiravir and tixagevimab-cilgavimab are available under Emergency Use Authorization or conditional approval. We discuss the potential application of these medications to protect travellers.
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Affiliation(s)
- Lin H Chen
- Department of Medicine, Mount Auburn Hospital, Cambridge, Massachusetts, and Harvard Medical School, Boston, MA, USA
| | - Bradley A Connor
- Department of Medicine, Weill Cornell Medical College and the New York Center for Travel and Tropical Medicine, New York, NY, USA
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11
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Impact of international travel and diarrhea on gut microbiome and resistome dynamics. Nat Commun 2022; 13:7485. [PMID: 36470885 PMCID: PMC9722912 DOI: 10.1038/s41467-022-34862-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 11/08/2022] [Indexed: 12/11/2022] Open
Abstract
International travel contributes to the global spread of antimicrobial resistance. Travelers' diarrhea exacerbates the risk of acquiring multidrug-resistant organisms and can lead to persistent gastrointestinal disturbance post-travel. However, little is known about the impact of diarrhea on travelers' gut microbiomes, and the dynamics of these changes throughout travel. Here, we assembled a cohort of 159 international students visiting the Andean city of Cusco, Peru and applied next-generation sequencing techniques to 718 longitudinally-collected stool samples. We find that gut microbiome composition changed significantly throughout travel, but taxonomic diversity remained stable. However, diarrhea disrupted this stability and resulted in an increased abundance of antimicrobial resistance genes that can remain high for weeks. We also identified taxa differentially abundant between diarrheal and non-diarrheal samples, which were used to develop a classification model that distinguishes between these disease states. Additionally, we sequenced the genomes of 212 diarrheagenic Escherichia coli isolates and found those from travelers who experienced diarrhea encoded more antimicrobial resistance genes than those who did not. In this work, we find the gut microbiomes of international travelers' are resilient to dysbiosis; however, they are also susceptible to colonization by multidrug-resistant bacteria, a risk that is more pronounced in travelers with diarrhea.
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12
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Riccò M, Zaniboni A, Satta E, Baldassarre A, Cerviere MP, Marchesi F, Peruzzi S. Management and Prevention of Traveler's Diarrhea: A Cross-Sectional Study on Knowledge, Attitudes, and Practices in Italian Occupational Physicians (2019 and 2022). Trop Med Infect Dis 2022; 7:370. [PMID: 36422921 PMCID: PMC9692574 DOI: 10.3390/tropicalmed7110370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 07/29/2023] Open
Abstract
Even though Italian Occupational Physicians (OP) are increasingly involved in the managing of overseas workers, their knowledge, attitudes, and practices (KAP) in travel medicine are mostly undefined. We, therefore, permed a KAP study specifically targeting the management of travelers' diarrhea (TD) by OP. A total of 371 professionals (43.4% males; mean age 40.8 ± 10.9 years) completed in 2 rounds (2019 and 2022) a specifically designed web questionnaire that inquired participating OP on their knowledge status (KS), risk perception, and management of TD through pre- and post-travel advice and interventions. Multivariable odds ratios (aOR) for predictors of a better knowledge status were calculated through regression analysis. Eventually, the majority of participants (53.4%) had participated in the management of cases of TD in the previous months, but only 26.4% were reportedly involved in pre-travel consultations. The overall knowledge status was unsatisfying (potential range: 0-100%, actual average of the sample 59.6% ± 14.6), with substantial uncertainties in the management of antimicrobial treatment. Interestingly, only a small subset of participants had previously prescribed antimicrobial prophylaxis or treatment (3.5% and 1.9%, respectively). Main effectors of a better knowledge status were: having a background qualification in Hygiene and Public Health (aOR 14.769, 95%CI 5.582 to 39.073), having previously managed any case of (aOR 3.107, 95%CI 1.484 to 6.506), and having higher concern on TD, reported by acknowledging high frequency (aOR 8.579, 95%CI 3.383 to 21.756) and severity (aOR 3.386; 95%CI 1.741 to 6.585) of this disorder. As the adherence of participating OP to official recommendations for TD management was unsatisfying, continuous Education on Travel Medicine should be improved by sharing up-to-date official recommendations on appropriate treatment options for TD.
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Affiliation(s)
- Matteo Riccò
- Servizio di Prevenzione e Sicurezza Negli Ambienti di Lavoro (SPSAL), Department of Public Health, AUSL-IRCCS di Reggio Emilia, I-42122 Reggio Emilia, Italy
| | - Alessandro Zaniboni
- Department of Medicine and Surgery, University of Parma, I-43126 Parma, Italy
| | - Elia Satta
- Department of Medicine and Surgery, University of Parma, I-43126 Parma, Italy
| | - Antonio Baldassarre
- Department of Experimental and Clinical Medicine, University of Florence, I-50134 Florence, Italy
| | | | - Federico Marchesi
- Department of Medicine and Surgery, University of Parma, I-43126 Parma, Italy
| | - Simona Peruzzi
- Laboratorio Analisi Chimico Cliniche e Microbiologiche, Ospedale Civile di Guastalla, AUSL-IRCCS di Reggio Emilia, I-42016 Guastalla, Italy
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13
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Gefen-Halevi S, Biber A, Gazit Z, Amit S, Belausov N, Keller N, Smollan G, Schwartz E. Persistent abdominal symptoms in returning travellers: clinical and molecular findings. J Travel Med 2022; 29:6520889. [PMID: 35134178 DOI: 10.1093/jtm/taac011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/06/2022] [Accepted: 01/12/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Persistent abdominal symptoms (PAS) are the leading cause of post-travel morbidity although there is a paucity of evidence concerning the aetiology of this condition. Recently molecular methods for protozoa detection in stool have been introduced. Herein, we describe the clinical aspects and the prevalence of gastrointestinal protozoa in returning travellers with PAS. METHODS From 2017 to 2019, clinical information and stool specimens from returning travellers with PAS were analysed for the presence of parasites using the Allplex-GI-Parasite-assay. Stool findings from symptomatic patients without a travel history were used as a comparator. RESULTS During the 2-year study, 203 stool specimens from returning travellers were analysed. The median duration of symptoms before seeking care was 6 months, the most common symptoms were fatigue (79.2%), abdominal pain (75.7%) and loose stool (70.8%).Most of travellers had returned from Asia (57.6%), mainly from the Indian-subcontinent and only 52.6% were backpackers. Altogether, 36.9% samples were positive for protozoa, with Blastocystis hominis being the most common (26.6%) in samples, followed by Dientamoeba fragilis (18.7%), Giardia lamblia (3.0%) and Cryptosporidium spp (0.5%). The former two were dominant in all regions. In all cases but one, G. lamblia was acquired, but one were acquired in the Indian subcontinent (odds ratios 16.9; 95% confidence intervals: 1.9-148.3). Entamoeba histolytica was not detected. The demographic characterization of the 1359 non-travellers was comparable with the travellers. Among them D. fragilis was the most common followed by B. hominis, which was significantly less frequent compared among the travellers (16.7% vs 26.6%, P < 0.001). Average Cycle threshold values for each stool parasites were comparable between the two groups. CONCLUSION Among returning travellers with PAS, more than one-third were positive for gastrointestinal protozoa. A low rate of giardia was found and no E. histolytica while B. hominis followed by D. fragilis were the dominant findings. Further studies are required to better understand the role of these protozoa in PAS.
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Affiliation(s)
- Shiraz Gefen-Halevi
- Clinical Microbiology Laboratory, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Asaf Biber
- The Center for Geographic Medicine and Tropical Diseases, Sheba Medical Center, Ramat Gan 52621, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
| | - Zeala Gazit
- Clinical Microbiology Laboratory, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Sharon Amit
- Clinical Microbiology Laboratory, Sheba Medical Center, Ramat Gan 52621, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
| | - Natasha Belausov
- Clinical Microbiology Laboratory, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Nati Keller
- School of Health Sciences, Ariel University, Ariel 40700, Israel.,Clinical Microbiology Laboratory, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Gill Smollan
- Clinical Microbiology Laboratory, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Eli Schwartz
- The Center for Geographic Medicine and Tropical Diseases, Sheba Medical Center, Ramat Gan 52621, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
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14
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Pender MA, Smith T, Brintz BJ, Pandey P, Shrestha SK, Anuras S, Demons S, Sornsakrin S, Bodhidatta L, Platts-Mills JA, Leung DT. Weather variables as important clinical predictors of bacterial diarrhoea among international travellers. J Travel Med 2022; 29:6520888. [PMID: 35134202 PMCID: PMC9282096 DOI: 10.1093/jtm/taac012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/19/2022] [Accepted: 01/27/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Clinicians and travellers often have limited tools to differentiate bacterial from non-bacterial causes of travellers' diarrhoea (TD). Development of a clinical prediction rule assessing the aetiology of TD may help identify episodes of bacterial diarrhoea and limit inappropriate antibiotic use. We aimed to identify predictors of bacterial diarrhoea among clinical, demographic and weather variables, as well as to develop and cross-validate a parsimonious predictive model. METHODS We collected de-identified clinical data from 457 international travellers with acute diarrhoea presenting to two healthcare centres in Nepal and Thailand. We used conventional microbiologic and multiplex molecular methods to identify diarrheal aetiology from stool samples. We used random forest and logistic regression to determine predictors of bacterial diarrhoea. RESULTS We identified 195 cases of bacterial aetiology, 63 viral, 125 mixed pathogens, 6 protozoal/parasite and 68 cases without a detected pathogen. Random forest regression indicated that the strongest predictors of bacterial over viral or non-detected aetiologies were average location-specific environmental temperature and red blood cell on stool microscopy. In 5-fold cross-validation, the parsimonious model with the highest discriminative performance had an area under the receiver operator curve of 0.73 using 3 variables with calibration intercept -0.01 (standard deviation, SD 0.31) and slope 0.95 (SD 0.36). CONCLUSIONS We identified environmental temperature, a location-specific parameter, as an important predictor of bacterial TD, among traditional patient-specific parameters predictive of aetiology. Future work includes further validation and the development of a clinical decision-support tool to inform appropriate use of antibiotics in TD.
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Affiliation(s)
- Melissa A Pender
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Timothy Smith
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Ben J Brintz
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Prativa Pandey
- CIWEC Hospital Director, CIWEC Hospital, Kathmandu 44600, Nepal
| | - Sanjaya K Shrestha
- Department of Bacterial and Parasitic Diseases, Walter Reed/Armed Forces Research Institute of Medical Sciences Research Unit Nepal (WARUN), Kathmandu 44600, Nepal
| | - Sinn Anuras
- Department of Medicine, MedPark Hospital, Bangkok 10110, Thailand
| | - Samandra Demons
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok 10400, Thailand
| | - Siriporn Sornsakrin
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok 10400, Thailand
| | - Ladaporn Bodhidatta
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok 10400, Thailand
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, VA 22903, USA
| | - Daniel T Leung
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
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15
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Lόpez-Vélez R, Lebens M, Bundy L, Barriga J, Steffen R. Bacterial travellers' diarrhoea: A narrative review of literature published over the past 10 years. Travel Med Infect Dis 2022; 47:102293. [PMID: 35247581 DOI: 10.1016/j.tmaid.2022.102293] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Rogelio Lόpez-Vélez
- National Referral Unit for Tropical Diseases, Infectious Diseases Department, Ramón y Cajal University Hospital, IRYCIS, 28034, Madrid, Spain.
| | - Michael Lebens
- Department of Microbiology and Immunology, University of Gothenburg, Box 435, SE-40530, Gothenburg, Sweden.
| | - Leah Bundy
- Elements Communications Ltd, Westerham, TN16 1RQ, UK.
| | - Juan Barriga
- Department of Medical Affairs Europe, Emergent BioSolutions, 1455, Madrid, Spain.
| | - Robert Steffen
- Epidemiology, Biostatistics and Prevention Institute, World Health Organization Collaborating Centre for Travelers' Health, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland; Epidemiology, Human Genetics and Environmental Sciences Division, University of Texas School of Public Health, Houston, TX 77030, Texas, USA.
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16
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Tisdale MD, Tribble DR, Mitra I, Telu K, Kuo HC, Fraser JA, Liu J, Houpt ER, Riddle MS, Tilley DH, Kunz AN, Yun HC, Geist CC, Lalani T. TaqMan Array Card testing of participant-collected stool smears to determine the pathogen-specific epidemiology of travellers' diarrhoea†. J Travel Med 2022; 29:6365984. [PMID: 34494100 PMCID: PMC8763119 DOI: 10.1093/jtm/taab138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/17/2021] [Accepted: 08/19/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND We assessed the compliance with self-collection of stool smears on Whatman® FTA® Elute Card (FTA Card) and detection of travellers' diarrhoea (TD)-associated pathogens by using a quantitative Polymerase Chain Reaction (PCR) assay [customized TaqMan® array card (TAC)] in a prospective, observational cohort of travellers. METHODS Enrolled travellers documented symptoms on a travel diary and collected an FTA Card during a diarrhoeal episode, or at the end of travel if they remained asymptomatic. TAC testing was performed on FTA Cards from TD cases and 1:1 matched asymptomatic controls and 1:1 matched loose stool cases that did not meet TD criteria. Odds ratios were used to determine the association between detected pathogens and TD. RESULTS Of 2456 travellers, 484 (19.7%) completed an illness diary and met TD criteria, and 257 (53.1%) collected an FTA Card during the TD episode. FTA Cards were stored for a median of 2 years at room temperature (IQR: 1-4 years) before extraction and testing. The overall TAC detection rate in TD cases was 58.8% (95% CI: 52.5-64.8). Enterotoxigenic Escherichia coli was the most common pathogen in TD cases (26.8%), and 3.5% of samples were positive for norovirus. The odds of detecting TD-associated pathogens in 231 matched cases and asymptomatic controls were 5.4 (95% CI: 3.6-8.1) and 2.0 (95% CI: 1.1-3.7) in 121 matched TD and loose stool cases (P < 0.05). Enteroaggregative E. coli was the most common pathogen detected in asymptomatic controls and loose stool cases. Detection of diarrhoeagenic E. coli, Shigella/enteroinvasive E. coli and Campylobacter spp. was significantly associated with TD. CONCLUSION FTA Cards are a useful adjunct to traditional stool collection methods for evaluating the pathogen-specific epidemiology of TD in austere environments. Qualitative detection of pathogens was associated with TD. Measures to improve compliance and quality of FTA Card collection with decreased storage duration may further optimize detection.
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Affiliation(s)
- Michele D Tisdale
- To whom correspondence should be addressed. Infectious Disease & Travel Clinic, Building 3, 1st Floor, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA.
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17
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Kantele A, Lääveri T. Extended-spectrum beta-lactamase-producing strains among diarrhoeagenic Escherichia coli-prospective traveller study with literature review. J Travel Med 2022; 29:6217594. [PMID: 33834207 PMCID: PMC8763120 DOI: 10.1093/jtm/taab042] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 01/27/2020] [Accepted: 01/29/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Antibiotics are no longer the primary approach for treating all travellers' diarrhoea (TD): most cases resolve without antibiotics and using them predisposes to colonization by multidrug-resistant bacteria. Data are accumulating on increasing resistance among TD pathogens, yet research into the most common agents, diarrhoeagenic Escherichia coli (DEC), remains limited. METHODS A total of 413 travellers to the (sub)tropics were analyzed for travel-acquired diarrhoeal pathogens and ESBL-PE. To identify ESBL-producing DEC, ESBL-producing E. coli (ESBL-EC) isolates were subjected to multiplex qPCR for various DEC pathotypes: enteroaggregative (EAEC), enteropathogenic (EPEC), enterotoxigenic (ETEC), enteroinvasive (EIEC) and enterohaemorrhagic (EHEC) E. coli.For a literature review, we screened studies among travellers and locals in low- and middle-income countries (LMICs) on the frequency of ESBL-producing DEC, and among travellers, also DEC with resistance to ciprofloxacin, azithromycin, and rifamycin derivatives. RESULTS Our rate of ESBL-EC among all DEC findings was 2.7% (13/475); among EAEC 5.7% (10/175), EPEC 1.1% (2/180), ETEC 1.3% (1/80) and EHEC (0/35) or EIEC 0% (0/5). The literature search yielded three studies reporting ESBL-EC frequency and thirteen exploring resistance to TD antibiotics among travel-acquired DEC. For EAEC and ETEC, the ESBL-EC rates were 10-13% and 14-15%, resistance to fluoroquinolones 0-42% and 0-40%, azithromycin 0-29% and 0-61%, and rifaximin 0% and 0-20%. The highest rates were from the most recent collections. Proportions of ESBL-producing DEC also appear to be increasing among locals in LMICs and even carbapenemase-producing DEC were reported. CONCLUSION ESBL producers are no longer rare among DEC, and the overall resistance to various antibiotics is increasing. The data predict decreasing efficacy of antibiotic treatment, threatening its benefits, for disadvantages still prevail when efficacy is lost.
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Affiliation(s)
- Anu Kantele
- To whom correspondence should be addressed. Professor Anu Kantele, Meilahti Vaccine Research Center MeVac, University of Helsinki and Helsinki University Hospital, Biomedicum 1, Haartmaninkatu 8, FI-00029 HUS, Finland; Tel: +358-50-309-7640;
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18
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Teh R, Tee WD, Tan E, Fan K, Koh CJ, Tambyah PA, Oon J, Tee N, Soh AYS, Siah KTH. Review of the role of gastrointestinal multiplex polymerase chain reaction in the management of diarrheal illness. J Gastroenterol Hepatol 2021; 36:3286-3297. [PMID: 34129249 DOI: 10.1111/jgh.15581] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/19/2021] [Accepted: 06/13/2021] [Indexed: 01/25/2023]
Abstract
Acute and chronic diarrheal illness secondary to gastrointestinal infection is a significant cause of morbidity and mortality around the world. A cornerstone of management includes prompt diagnosis and appropriate treatment of culprit pathogens. Timely diagnosis can improve patient care, assist in infection control, and prevent disease outbreaks. Historical methods of diagnosis include traditional culture methods and stool analysis. These are limited by long turnaround time and inability to simultaneously assess multiple pathogens. The advent of multiplexed nucleic acid amplification tests first began with the Food and Drug Administration-approved respiratory virus multiplex polymerase chain reaction (PCR) panel in 2009, followed by gastrointestinal infections in 2013, and neurological infections in 2014. We conducted a review of current literature pertaining to the clinical utility of a gastrointestinal multiplex PCR in management of acute and chronic diarrhea in patients. To date, seven platforms approved by the US Food and Drug Administration are used in detection of various bacterial, viral, and parasitic causative organisms for diagnosis of gastrointestinal infections. The sensitivity and specificity of each assay vary depending on the tested organism. Interpretation of a positive result has to be tailored to the clinical context. Further studies are required to establish the utility of gastrointestinal multiplex PCR from a cost-based perspective, whether specific enteropathogens such as Clostridioides difficile are better assessed with toxin gene detection and whether new parameters such as cycle threshold values can improve clinical application of test results.
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Affiliation(s)
- Readon Teh
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore
| | - Wei De Tee
- Division of Gastroenterology and Hepatology, Ng Teng Fong General Hospital, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Eunice Tan
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kristie Fan
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Calvin Jianyi Koh
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Paul Ananth Tambyah
- Division of Infectious Diseases, National University Hospital, Singapore.,Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jolene Oon
- Division of Infectious Diseases, National University Hospital, Singapore
| | - Nancy Tee
- Department of Laboratory Medicine, National University Hospital, Singapore
| | - Alex Yu Sen Soh
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kewin Tien Ho Siah
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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19
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Costello VH, Tribble D, Eickhoff C, Tilley DH, Utz G, Telu K, Ganesan A, Fraser J, Lalani T. Travel-Related Risk Behaviors and Antibiotic Use Among Older Travelers. Open Forum Infect Dis 2021; 8:ofab395. [PMID: 34430673 PMCID: PMC8378587 DOI: 10.1093/ofid/ofab395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/27/2021] [Indexed: 11/13/2022] Open
Abstract
Background Antibiotic stewardship in the pretravel care of older adults is important to effectively treat infections while minimizing harm from side effects and unnecessary antibiotic use. The objective of this study was to compare the characteristics, risk behaviors, infectious diseases, and antibiotic use between older (≥60 years) and younger (18-59 years) travelers. Methods TravMil is a prospective, observational cohort of United States (US) Department of Defense beneficiaries traveling outside the continental US for ≤6.5 months. For this analysis, we included adults enrolled pretravel between January 2010 and August 2018 and excluded active duty personnel on deployment. Pre and post-travel surveys captured trip characteristics, exposures, illnesses, and antibiotic use. Results A total of 1742 travelers were analyzed: 747 (42.9%) were aged ≥60 years and 995 (57.1%) were aged 18-59 years. Older travelers were less likely to engage in high-risk dietary behaviors and experience travelers' diarrhea than younger travelers (18.2% vs 22.9%; P < .05). Influenza-like illness (12.5%) and febrile illness (3.4%) occurred less frequently in the older cohort. Antibiotic use for self-treatment was common in both age groups (25.7% vs 26.7%) and often inappropriate, for example, for treatment of occasional loose stool or mild travelers' diarrhea (67.0% [67/100] in older adults vs 57.6% [83/144] in younger adults; P < .05), and influenza-like illness (63.4% [64/101] vs 58.6% [68/116], respectively; P < .05). Conclusions Older travelers were less likely to engage in high-risk behaviors and experience travelers' diarrhea, and both age groups experienced mild, self-limited infections. Inappropriate use of antibiotics was common, suggesting that antimicrobial stewardship should be emphasized at pretravel counseling with international travelers.
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Affiliation(s)
| | - David Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | | | | | - Gregory Utz
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Naval Medical Center San Diego, San Diego, California, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland, USA
| | - Kalyani Telu
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland, USA
| | - Anuradha Ganesan
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland, USA.,Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Jamie Fraser
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland, USA
| | - Tahaniyat Lalani
- Naval Medical Center Portsmouth, Portsmouth, Virginia, USA.,Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland, USA
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20
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Update on Shigella and nontyphoidal Salmonella antimicrobial drug resistance: Implications on empiric treatment of acute infectious diarrhea in Cambodia. Antimicrob Agents Chemother 2021; 65:e0067121. [PMID: 34398671 DOI: 10.1128/aac.00671-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Information on causative diarrheal pathogens and their associated antimicrobial susceptibility remains limited for Cambodia. This study describes antimicrobial resistance patterns for Shigella and nontyphoidal Salmonella isolates collected in Cambodia over a five-year period. Multidrug resistance was shown in 98% of Shigella isolates, with 70%, 11%, and 29% of isolates being resistant to fluoroquinolones, azithromycin, and cephalosporin, respectively. As many as 11% of Shigella isolates were resistant to nearly all oral and parenteral drugs typically used for shigellosis, demonstrating extreme drug-resistance phenotypes. Although a vast majority of nontyphoidal Salmonella isolates remained susceptible to cephalosporins (99%) and macrolides (98%), decreased susceptibility to ciprofloxacin was found in 67% of isolates, which is notably higher than previous reports. In conclusion, increasing antimicrobial resistance of Shigella and nontyphoidal Salmonella is a major concern for selecting empiric treatment of acute infectious diarrhea in Cambodia. Treatment practices should be updated and follow local antimicrobial resistance data for the identified pathogens.
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21
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Yoo IH, Kang HM, Suh W, Cho H, Yoo IY, Jo SJ, Park YJ, Jeong DC. Quality Improvements in Management of Children with Acute Diarrhea Using a Multiplex-PCR-Based Gastrointestinal Pathogen Panel. Diagnostics (Basel) 2021; 11:diagnostics11071175. [PMID: 34203426 PMCID: PMC8303787 DOI: 10.3390/diagnostics11071175] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 11/16/2022] Open
Abstract
Conventional methods for etiologic diagnoses of acute gastroenteritis (AGE) are time consuming and have low positive yield leading to limited clinical value. This study aimed to investigate quality improvements in patient management, antibiotic stewardship, and in-hospital infection transmission prevention using BioFire® FilmArray® Gastrointestinal Panel (GI Panel) in children with acute diarrhea. This was a prospective study recruiting children < 19 years old with new onset diarrhea during the study period, and a matched historical cohort study of children diagnosed with AGE during the 4 years prior. Patients in the prospective cohort underwent stool testing with GI Panel and conventional methods. A total of 182 patients were included in the prospective cohort, of which 85.7% (n = 156) had community-onset and 14.3% (n = 26) had hospital-onset diarrhea. A higher pathogen positivity rate for community-onset diarrhea was observed by the GI Panel (58.3%, n = 91) compared to conventional studies (42.3%, n = 66) (p = 0.005) and historical cohort (31.4%, n = 49) (p < 0.001). The stool tests reporting time after admission was 25 (interquartile range, IQR 17-46) hours for the GI Panel, and 72 (IQR 48-96) hours for the historical cohort (p < 0.001). A significant reduction in antibiotic use was observed in the prospective cohort compared to historical cohort, 35.3% vs. 71.8%; p < 0.001), respectively. Compared to the GI Panel, norovirus ICT was only able to detect 4/11 (36.4%) patients with hospital-onset and 14/27 (51.8%) patients with community-onset diarrhea. The high positivity rate and rapid reporting time of the GI Panel had clinical benefits for children admitted for acute diarrhea, especially by reducing antibiotic use and enabling early adequate infection precaution and isolation.
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Affiliation(s)
- In Hyuk Yoo
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Hyun Mi Kang
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
- Correspondence: (H.M.K.); (D.C.J.); Tel.: +82-2-2258-6273 (H.M.K.); +82-2-2258-6180 (D.C.J.); Fax: +82-2-537-4544 (H.M.K. & D.C.J.)
| | - Woosuk Suh
- Uijeongbu Eulji Medical Center, Department of Pediatrics, Eulji University School of Medicine, Seongnam 11759, Korea;
| | - Hanwool Cho
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (H.C.); (I.Y.Y.); (S.J.J.); (Y.J.P.)
| | - In Young Yoo
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (H.C.); (I.Y.Y.); (S.J.J.); (Y.J.P.)
| | - Sung Jin Jo
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (H.C.); (I.Y.Y.); (S.J.J.); (Y.J.P.)
| | - Yeon Joon Park
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (H.C.); (I.Y.Y.); (S.J.J.); (Y.J.P.)
| | - Dae Chul Jeong
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
- Correspondence: (H.M.K.); (D.C.J.); Tel.: +82-2-2258-6273 (H.M.K.); +82-2-2258-6180 (D.C.J.); Fax: +82-2-537-4544 (H.M.K. & D.C.J.)
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22
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Johnson RC, Van Nostrand JD, Tisdale M, Swierczewski B, Simons MP, Connor P, Fraser J, Melton-Celsa AR, Tribble DR, Riddle MS. Fecal Microbiota Functional Gene Effects Related to Single-Dose Antibiotic Treatment of Travelers' Diarrhea. Open Forum Infect Dis 2021; 8:ofab271. [PMID: 34189178 DOI: 10.1093/ofid/ofab271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/25/2021] [Indexed: 11/14/2022] Open
Abstract
Background Travelers' diarrhea (TD) is common among military personnel deployed to tropical and subtropical regions. It remains unclear how TD and subsequent antibiotic treatment impact the resident microflora within the gut, especially given increased prevalence of antibiotic resistance among enteric pathogens and acquisition of multidrug-resistant organisms. We examined functional properties of the fecal microflora in response to TD, along with subsequent antibiotic treatment. Methods Fecal samples from US and UK military service members deployed to Djibouti, Kenya, and Honduras who presented with acute watery diarrhea were collected. A sample was collected at acute presentation to the clinic (day 0, before antibiotics), as well as 7 and/or 21 days following a single dose of antibiotics (azithromycin [500 mg], levofloxacin [500 mg], or rifaximin [1650 mg], all with loperamide). Each stool sample underwent culture and TaqMan reverse transcription polymerase chain reaction analyses for pathogen and antibiotic resistance gene detection. Purified DNA from each sample was analyzed using the HumiChip3.1 functional gene array. Results In total, 108 day 1 samples, 50 day 7 samples, and 94 day 21 samples were available for analysis from 119 subjects. Geographic location and disease severity were associated with distinct functional compositions of fecal samples. There were no overt functional differences between pre- and postantibiotic treatment samples, nor was there increased acquisition of antibiotic resistance determinants for any of the antibiotic regimens. Conclusions These results indicate that single-dose antibiotic regimens may not drastically alter the functional or antibiotic resistance composition of fecal microflora, which should inform clinical practice guidelines and antimicrobial stewardship. Clinical Trials Registration Number NCT01618591.
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Affiliation(s)
- Ryan C Johnson
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Joy D Van Nostrand
- Department of Microbiology and Plant Biology, Institute for Environmental Genomics, University of Oklahoma, Norman, Oklahoma, USA
| | - Michele Tisdale
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA.,Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Naval Medical Center, Portsmouth, Virginia, USA
| | | | - Mark P Simons
- Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Patrick Connor
- Department of Military Medicine, Royal Centre for Defense Medicine, Birmingham, UK
| | - Jamie Fraser
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA.,Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Angela R Melton-Celsa
- Department of Microbiology and Immunology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - David R Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Mark S Riddle
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Department of Internal Medicine, University of Nevada Reno, School of Medicine, Reno, Nevada, USA
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23
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Chehab H, Fischer PR, Christenson JC. Preparing Children for International Travel. Pediatr Rev 2021; 42:189-202. [PMID: 33795465 DOI: 10.1542/pir.2018-0353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Hiba Chehab
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, IN
| | - Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN.,Pediatrics Department, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - John C Christenson
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, IN
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24
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Souza LKM, Nogueira KM, Araújo TSL, Sousa NA, Sousa FBM, Oliveira AP, Sales T, Silva K, Rocha TM, Leal LKAM, Magalhães PJC, Souza MHLP, Medeiros JVR. Anti-diarrheal therapeutic potential of diminazene aceturate stimulation of the ACE II/Ang-(1-7)/Mas receptor axis in mice: A trial study. Biochem Pharmacol 2021; 186:114500. [PMID: 33684388 DOI: 10.1016/j.bcp.2021.114500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/17/2021] [Accepted: 02/26/2021] [Indexed: 11/17/2022]
Abstract
The angiotensin (Ang) II converting enzyme (ACE II) pathway has recently been shown to be associated with several beneficial effects on the body, especially on the cardiac system and gastrointestinal tract. ACE II is responsible for converting Ang II into the active peptide Ang-(1-7), which in turn binds to a metabotropic receptor, the Mas receptor (MasR). Recent studies have demonstrated that Diminazene Aceturate (DIZE), a trypanosomicide used in animals, activates the ACE II pathway. In this study, we aimed to evaluate the antidiarrheal effects promoted by the administration of DIZE to activate the ACE II/Ang-(1-7)/MasR axis in induced diarrhea mice models. The results show that activation of the ACE II pathway exerts antidiarrheal effects that reduce total diarrheal stools and enteropooling. In addition, it increases Na+/K+-ATPase activity and reduces gastrointestinal transit and thus inhibits contractions of intestinal smooth muscle; decreases transepithelial electrical resistance, epithelial permeability, PGE2-induced diarrhea, and proinflammatory cytokines; and increases anti-inflammatory cytokines. Enzyme-linked immunosorbent assay (ELISA) demonstrated that DIZE, when activating the ACE II/Ang-(1-7)/MasR axis, can still interact with GM1 receptors, which reduces cholera toxin-induced diarrhea. Therefore, activation of the ACE II/Ang-(1-7)/MasR axis can be an important pharmacological target for the treatment of diarrheal diseases.
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Affiliation(s)
- Luan K M Souza
- The Northeast Biotechnology Network (RENORBIO), Federal University of Piauí, Teresina, PI 64049-550, Brazil; Laboratory of Pharmacology of Inflammation and Gastrointestinal Disorders (Lafidg), Federal University of Parnaíba Delta (UFDPar), Av. São Sebastião, n° 2819, CEP 64202-02 Parnaíba, PI, Brazil.
| | - Kerolayne M Nogueira
- Department of Physiology and Pharmacology, Federal University of Ceará, Fortaleza, CE 60430-275, Brazil
| | - Thiago S L Araújo
- The Northeast Biotechnology Network (RENORBIO), Federal University of Piauí, Teresina, PI 64049-550, Brazil; Laboratory of Pharmacology of Inflammation and Gastrointestinal Disorders (Lafidg), Federal University of Parnaíba Delta (UFDPar), Av. São Sebastião, n° 2819, CEP 64202-02 Parnaíba, PI, Brazil
| | - Nayara A Sousa
- The Northeast Biotechnology Network (RENORBIO), Federal University of Piauí, Teresina, PI 64049-550, Brazil; Laboratory of Pharmacology of Inflammation and Gastrointestinal Disorders (Lafidg), Federal University of Parnaíba Delta (UFDPar), Av. São Sebastião, n° 2819, CEP 64202-02 Parnaíba, PI, Brazil
| | - Francisca B M Sousa
- The Northeast Biotechnology Network (RENORBIO), Federal University of Piauí, Teresina, PI 64049-550, Brazil; Laboratory of Pharmacology of Inflammation and Gastrointestinal Disorders (Lafidg), Federal University of Parnaíba Delta (UFDPar), Av. São Sebastião, n° 2819, CEP 64202-02 Parnaíba, PI, Brazil
| | - Ana P Oliveira
- The Northeast Biotechnology Network (RENORBIO), Federal University of Piauí, Teresina, PI 64049-550, Brazil; Laboratory of Pharmacology of Inflammation and Gastrointestinal Disorders (Lafidg), Federal University of Parnaíba Delta (UFDPar), Av. São Sebastião, n° 2819, CEP 64202-02 Parnaíba, PI, Brazil
| | - Thiago Sales
- Department of Physiology and Pharmacology, Federal University of Ceará, Fortaleza, CE 60430-275, Brazil
| | - Karine Silva
- Department of Physiology and Pharmacology, Federal University of Ceará, Fortaleza, CE 60430-275, Brazil
| | - Talita M Rocha
- Department of Physiology and Pharmacology, Federal University of Ceará, Fortaleza, CE 60430-275, Brazil
| | - Luzia K A M Leal
- Department of Physiology and Pharmacology, Federal University of Ceará, Fortaleza, CE 60430-275, Brazil
| | - Pedro J C Magalhães
- Department of Physiology and Pharmacology, Federal University of Ceará, Fortaleza, CE 60430-275, Brazil
| | - Marcellus H L P Souza
- Department of Physiology and Pharmacology, Federal University of Ceará, Fortaleza, CE 60430-275, Brazil
| | - Jand V R Medeiros
- The Northeast Biotechnology Network (RENORBIO), Federal University of Piauí, Teresina, PI 64049-550, Brazil; Laboratory of Pharmacology of Inflammation and Gastrointestinal Disorders (Lafidg), Federal University of Parnaíba Delta (UFDPar), Av. São Sebastião, n° 2819, CEP 64202-02 Parnaíba, PI, Brazil; Biotechnology and Biodiversity Center Research, BIOTEC, Federal University of Parnaíba Delta, Parnaíba, PI 64202-020, Brazil
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25
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Alasmari AK, Edwards PJ, Assiri AM, Behrens RH, Bustinduy AL. Use of face masks and other personal preventive measures by Hajj pilgrims and their impact on health problems during the Hajj. J Travel Med 2020; 27:5903249. [PMID: 32901805 DOI: 10.1093/jtm/taaa155] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/25/2020] [Accepted: 08/24/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND The Hajj is one of the world's largest pilgrimage and gathers millions of Muslims from different nationalities every year. Communicable diseases have been reported frequently, during and following the Hajj, and these have been linked to individual behavioural measures. This study aimed to measure the effect of personal preventive measures, such as face mask use, hand hygiene and others, adopted by pilgrims in reducing the acquisition of infectious diseases. METHODS We conducted a cross-sectional study at the Hajj terminal in King Abdulaziz International Airport in Jeddah, Saudi Arabia. Pilgrims were approached in the airport lounges after the 2017 Hajj season and prior to the departure of their flights from Jeddah to their home countries. An electronic data collection tool ('Open Data Kit') was used to gather survey data in regards to health problems and preventive measures during the Hajj. RESULTS A total of 2973 Hajj pilgrims were surveyed. In all, 38.7% reported symptoms of upper respiratory tract infections (URTIs) and 5.4% reported symptoms of travel diarrhoea. Compliance with face mask use was 50.2%. Changing a face mask every 4 h was found to be significantly associated with lower prevalence of URTIs [adjusted odds ratio 0.56 (95% confidence interval 0.34-0.92), P = 0.02]. There was no statistical difference between overall face mask use and URTI acquisition. The main sources of food, eating raw vegetables/food, frequency of hand washing or use of hand sanitizers were not found to be significantly associated with reported travellers' diarrhoea. Unlicensed barbers were used by 12% of pilgrims and 9.2% of pilgrims reported using blades that were reused by other pilgrims. CONCLUSION Preventive measures are the most effective way to prevent infections. Pilgrims can benefit from face masks by changing them frequently. There is still limited information on the effect of the use of face mask in decreasing the risk of URTI in mass gatherings.
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Affiliation(s)
- Abrar K Alasmari
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Phil J Edwards
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Abdullah M Assiri
- Preventive Health, Ministry of Health, Riyadh, Kingdom of Saudi Arabia
| | - Ronald H Behrens
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Amaya L Bustinduy
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
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26
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Ricco M, Gualerzi G, Ranzieri S. Personal beliefs and misconceptions, not evidence guide general practitioners in the managing of travelers' diarrhea: Results from a pilot study (North-Western Italy, 2019). Infect Dis Now 2020; 51:266-272. [PMID: 33160008 DOI: 10.1016/j.medmal.2020.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/27/2020] [Accepted: 10/27/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The present study aims to characterize knowledge, attitudes and practices in a sample of general practitioners (GPs) on management of travelers' diarrhea (TD). METHODS A total of 158 GPs (44.3% males; mean age 40.2±12.4 years) completed a web questionnaire on antibiotic prophylaxis (AP) and/or an antibiotic treatment (AT) in TD cases. Participants were inquired on knowledge status (KS), risk perception and effectively applied recommendations for AP/AT through a specifically designed questionnaire. Multivariate odds ratios (OR) for predictors of AP/AT were calculated through regression analysis. RESULTS All in all, while 15 (9.5%) participants recommended AP for TD, 61 of them (39.4%) recommended AT. KS was largely unsatisfying as participants extensively ignored the most recent AP/AT recommendations. Acknowledgment of TD as a severe disorder was predictive for recommendation of AP (OR 37.843, 95%CI 4.752-301.4). As for AT, it was relatively elevated in GPs≥10 years (OR 2.653, 95%CI 1.169-6.019), but more rarely reported in participants with higher KS (OR 0.056, 95%CI 0.021-0.153). CONCLUSIONS Adherence of GPs to official recommendations for TD management was unsatisfying, particularly in older participants. Continuous Education of GPs should be improved by sharing up-to-date official recommendations on AT/AP for TD.
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Affiliation(s)
- Matteo Ricco
- IRCCS-AUSL di Reggio Emilia; Service for Health and Safety in the Workplace, Department of Public Health, Via Amendola n.2, 42122 Reggio Emilia (RE), Italy.
| | - Giovanni Gualerzi
- Department of Medicine and Surgery; School of Medicine, University of Parma, Via Gramsci n.14, Parma (PR), Italy
| | - Silvia Ranzieri
- Department of Medicine and Surgery, School of Occupational Medicine, University of Parma, Via Gramsci n.14, Parma (PR), Italy
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Terra DADA, Vilela EG, Silva ROS, LeÃo LA, Lima KS, Passos RIFÂ, Diniz AN, Coelho LGV. STRUCTURING A FECAL MICROBIOTA TRANSPLANTATION CENTER IN A UNIVERSITY HOSPITAL IN BRAZIL. ARQUIVOS DE GASTROENTEROLOGIA 2020; 57:434-458. [PMID: 33331486 DOI: 10.1590/s0004-2803.202000000-79] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/30/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Fecal microbiota transplantation (FMT) is an important therapeutic option for recurrent or refractory Clostridioides difficile infection, being a safe and effective method. Initial results suggest that FMT also plays an important role in other conditions whose pathogenesis involves alteration of the intestinal microbiota. However, its systematized use is not widespread, especially in Brazil. In the last decade, multiple reports and several cases emerged using different protocols for FMT, without standardization of methods and with variable response rates. In Brazil, few isolated cases of FMT have been reported without the implantation of a Fecal Microbiota Transplantation Center (FMTC). OBJECTIVE The main objective of this study is to describe the process of implanting a FMTC with a stool bank, in a Brazilian university hospital for treatment of recurrent and refractory C. difficile infection. METHODS The center was structured within the criteria required by international organizations such as the Food and Drug Administration, the European Fecal Microbiota Transplant Group and in line with national epidemiological and regulatory aspects. RESULTS A whole platform involved in structuring a transplant center with stool bank was established. The criteria for donor selection, processing and storage of samples, handling of recipients before and after the procedure, routes of administration, short and long-term follow-up of transplant patients were determined. Donor selection was conducted in three stages: pre-screening, clinical evaluation and laboratory screening. Most of the candidates were excluded in the first (75.4%) and second stage (72.7%). The main clinical exclusion criteria were: recent acute diarrhea, overweight (body mass index ≥25 kg/m2) and chronic gastrointestinal disorders. Four of the 134 candidates were selected after full screening, with a donor detection rate of 3%. CONCLUSION The implantation of a transplant center, unprecedented in our country, allows the access of patients with recurrent or refractory C. difficile infection to innovative, safe treatment, with a high success rate and little available in Brazil. Proper selection of qualified donors is vital in the process of implementing a FMTC. The rigorous clinical evaluation of donors allowed the rational use of resources. A transplant center enables treatment on demand, on a larger scale, less personalized, with more security and traceability. This protocol provides subsidies for conducting FMT in emerging countries.
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Affiliation(s)
| | - Eduardo Garcia Vilela
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas / EBSERH, Universidade Federal de Mina Gerais, Belo Horizonte, MG, Brasil
| | | | - Laiane Alves LeÃo
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas / EBSERH, Universidade Federal de Mina Gerais, Belo Horizonte, MG, Brasil
| | - Karine Sampaio Lima
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas / EBSERH, Universidade Federal de Mina Gerais, Belo Horizonte, MG, Brasil
| | | | - Amanda Nádia Diniz
- Universidade Federal de Minas Gerais, Escola de Veterinária, Belo Horizonte, MG, Brasil
| | - Luiz Gonzaga Vaz Coelho
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas / EBSERH, Universidade Federal de Mina Gerais, Belo Horizonte, MG, Brasil
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Abstract
PURPOSE OF REVIEW With the growing popularity and commercialization of probiotics, it is important to understand the implications of existing randomized controlled trials and their applicability in the clinical setting to treat luminal gastrointestinal diseases. RECENT FINDINGS Probiotics may be useful in the prevention of antibiotic-associated diarrhea, prevention of Clostridioides difficile infection and eradication of Helicobacter pylori. Some evidence supports the use of probiotics in the treatment of ulcerative colitis, prevention and treatment of pouchitis and irritable bowel syndrome. Caution has to be exercised in immunocompromised and critically ill individuals. New society guidelines do not encourage probiotic use in gastrointestinal disorders with the exception of premature infants to prevent necrotizing enterocolitis. SUMMARY Despite burgeoning body of literature and wide acceptance by the public, a thorough understanding of efficacy and safety of probiotics is lacking. Uniform dosage, standardized clinical end points, personalization based on host microbial profile and longer duration of follow-up on the research front may help in the future in appropriate positioning of probiotics in health and disease.
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Affiliation(s)
- Abbinaya Elangovan
- Department of Internal Medicine-Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Monika Fischer
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
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Gandhi AR, Rao SR, Chen LH, Nelson MD, Ryan ET, LaRocque RC, Hyle EP. Prescribing Patterns of Antibiotics for the Self-Treatment of Travelers' Diarrhea in Global TravEpiNet, 2009-2018. Open Forum Infect Dis 2020; 7:ofaa376. [PMID: 33072808 PMCID: PMC7545114 DOI: 10.1093/ofid/ofaa376] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 08/25/2020] [Indexed: 12/26/2022] Open
Abstract
Background International travelers are often prescribed antibiotics for self-treatment of travelers' diarrhea (TD), but the benefits and risks of antibiotics are debated. We assessed the prescribing patterns of empiric antibiotics for TD in international travelers evaluated at Global TravEpiNet (GTEN) sites (2009-2018). Methods We performed a prospective, multisite cross-sectional study regarding antibiotic prescriptions for the self-treatment of TD at 31 GTEN sites providing pretravel consultations to adult international travelers. We described traveler demographics, itineraries, and antibiotic(s) prescribed. We used multivariable logistic regressions to assess the association of year of consultation with antibiotic prescribing (yes/no) and class (fluoroquinolones vs azithromycin). We performed interrupted time-series analyses to examine differences in prescribing before and after the Food and Drug Administration (FDA) warning on fluoroquinolones (July 2016). Results Antibiotics were not prescribed in 23 096 (22.2%) of 103 843 eligible pretravel GTEN consultations; azithromycin and fluoroquinolones were most frequently prescribed. Antibiotic prescribing declined significantly each year between 2009 and 2018 (odds ratio [OR], 0.84; 95% CI, 0.79-0.89), as did fluoroquinolone prescribing, relative to azithromycin (OR, 0.77; 95% CI, 0.73-0.82). The rate of decline in fluoroquinolone prescribing was significantly greater after the FDA fluoroquinolone warning (15.3%/year) than before (1.1%/year; P < .001). Conclusions Empiric antibiotics for TD were prescribed in >75% of pretravel GTEN consultations, but antibiotic prescribing declined steadily between 2009 and 2018. Fluoroquinolones were less frequently prescribed than azithromycin, especially after the 2016 FDA fluoroquinolone warning. Emphasis on the risks of antibiotics may influence antibiotic prescribing by providers for empiric treatment of TD.
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Affiliation(s)
- Aditya R Gandhi
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sowmya R Rao
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Lin H Chen
- Travel Medicine Center, Mount Auburn Hospital, Cambridge, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Michael D Nelson
- Travel Medicine Center, Mount Auburn Hospital, Cambridge, Massachusetts, USA
| | - Edward T Ryan
- Harvard Medical School, Boston, Massachusetts, USA.,Travelers' Advice and Immunization Center, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Regina C LaRocque
- Harvard Medical School, Boston, Massachusetts, USA.,Travelers' Advice and Immunization Center, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emily P Hyle
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Travelers' Advice and Immunization Center, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Formulation and Evaluation of Loperamide HCl Oro Dispersible Tablets. Pharmaceuticals (Basel) 2020; 13:ph13050100. [PMID: 32443638 PMCID: PMC7281284 DOI: 10.3390/ph13050100] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 05/08/2020] [Accepted: 05/14/2020] [Indexed: 12/21/2022] Open
Abstract
This work proposes the design of novel oral disintegrating tablets (ODTs) of loperamide HCl with special emphasis on disintegration and dissolution studies. The main goal was augmenting the adherence to treatment of diseases which happen with diarrhea in soldiers who are exposed to diverse kinds of hostile environments. Optimized orally disintegrating tablets were prepared by the direct compression method from galenic development to the industrial scale technique, thanks to strategic and support actions between the Spanish Army Force Lab and the Department of Biomedical Sciences (UAH). The results show that loperamide HCl ODT offers a rapid beginning of action and improvement in the bioavailability of poorly absorbed drugs. The manufactured ODTs complied with the pharmacopeia guidelines regarding hardness, weight variation, thickness, friability, drug content, wetting time, percentage of water absorption, disintegration time, and in vitro dissolution profile. Drug compatibility with excipients was checked by DSC, FTIR, and SEM studies.
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Brehm TT, Lütgehetmann M, Tannich E, Addo MM, Lohse AW, Rolling T, Vinnemeier CD. Risk factors for different intestinal pathogens among patients with traveler's diarrhea: A retrospective analysis at a German travel clinic (2009-2017). Travel Med Infect Dis 2020; 37:101706. [PMID: 32353630 DOI: 10.1016/j.tmaid.2020.101706] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 03/27/2020] [Accepted: 04/24/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Travelers' diarrhea (TD) is the most common illness experienced by travelers to developing regions of the world and may be caused by bacterial, parasitic or viral pathogens. The available diagnostic tests include stool microscopy for parasitic infections, culture-dependent methods for bacterial infections and molecular methods for bacterial, parasitic and viral infections. METHOD We retrospectively evaluated demographic, clinical and microbiological data of patients presenting with TD at our travel clinic between 2009 and 2017. RESULTS Among 676 patients with TD included in our study, at least one etiologic agent was found in 21% (n = 145) of cases. In total, 195 enteropathogens were detected of which 110 were bacteria, 70 protozoa and 15 helminths. Bacterial infections were significantly more common when symptoms were present less than 14 days and travel duration did not exceed 29 days. Protozoa and helminths were predominantly detected in patients with longer lasting complaints. After stool culture was replaced by a multiplex-PCR gastrointestinal pathogen panel (GPP) at our center, significantly more intestinal bacterial pathogens were detected. CONCLUSIONS Our results support an individualized approach in the diagnostic workup of patients with TD taking host and travel characteristics into account to avoid unnecessary diagnostic testing. Molecular culture-independent diagnostic stool tests provide better coverage of the variety of etiological agents than traditional stool culture and have the benefit of rapid detection. However, the high sensitivity bears challenges differentiating colonization from infection.
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Affiliation(s)
- Thomas Theo Brehm
- Division of Infectious Diseases, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20249, Hamburg, Germany; German Centre for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Germany.
| | - Marc Lütgehetmann
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20249, Hamburg, Germany; German Centre for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Germany.
| | - Egbert Tannich
- National Reference Centre for Tropical Pathogens, Bernhard-Nocht-Institute for Tropical Medicine, Bernhard-Nocht-Straße 74, 20359, Hamburg, Germany; German Centre for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Germany.
| | - Marylyn M Addo
- Division of Infectious Diseases, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20249, Hamburg, Germany; Department for Clinical Immunology of Infectious Diseases, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany; German Centre for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Germany.
| | - Ansgar W Lohse
- I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20249, Hamburg, Germany; German Centre for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Germany.
| | - Thierry Rolling
- Division of Infectious Diseases, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20249, Hamburg, Germany; German Centre for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Germany.
| | - Christof D Vinnemeier
- Division of Tropical Medicine, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20249, Hamburg, Germany; German Centre for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Germany.
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Song X, Wang Y, Kong X, Wang H, Huang X, Liu H, Liu L, Guo X, Zhang C, Zhao Y, Kou J, Wang H, Cheng P, Gong M. Toward the Elimination of Malaria in China: A Retrospective Analysis of Malaria-Endemic Characteristics and Prevention Effects in Yantai, Shandong Province, 1951 to 2017. Vector Borne Zoonotic Dis 2020; 20:197-204. [PMID: 31660782 PMCID: PMC7074888 DOI: 10.1089/vbz.2019.2504] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objectives: To study the epidemiological characteristics of malaria and the effects of comprehensive malaria control implementation in Yantai, as well as to provide a scientific basis for future malaria elimination. Materials and Methods: A retrospective analysis was conducted to explore the epidemiological changes and prevention effects in Yantai from 1951 to 2017. The malaria data before 2004 were collected from paper-based annual reports, and data after 2004 came from the Infectious Diseases Information Reporting Management System. Results: A total of 81,286 malaria cases were identified in Yantai from 1957 to 2017, with two peaks occurring in 1966 (120.93/100,000) and 1970-1972 (366.12/100,000). From 1951 to 2003, the case classification was mainly Plasmodium vivax (99.80%); the first case attributed to Plasmodium falciparum occurred in 2004, and P. falciparum became the main cause of malaria after 2011. All cases reported since 2010 have been imported cases, and the last indigenous case was caused by P. vivax in 2008. A total of 129 imported cases were reported from 2010 to 2017, most of which originated in Africa (93.80%), mainly in men aged 30-49 years (68.28%). From 1951 to 1973, 73,868 cases of malaria were diagnosed with clinical symptoms, and from 1974 to 2017, 818,943 cases in fever patients were diagnosed with blood tests. Conclusions: To achieve the goal of eliminating malaria by 2020, Yantai should continue to strengthen the management of migrant population, including improving malaria surveillance for returnees and immigrants from overseas endemic areas, and continue to increase the training of medical personnel to improve their diagnostic ability.
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Affiliation(s)
- Xiao Song
- School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, China
- Shandong Institute of Parasitic Diseases, Shandong First Medical University & Shandong Academy of Medical Sciences, Jining, China
| | - Yang Wang
- School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, China
- Shandong Institute of Parasitic Diseases, Shandong First Medical University & Shandong Academy of Medical Sciences, Jining, China
| | - Xiangli Kong
- Shandong Institute of Parasitic Diseases, Shandong First Medical University & Shandong Academy of Medical Sciences, Jining, China
| | - Haifang Wang
- Shandong Institute of Parasitic Diseases, Shandong First Medical University & Shandong Academy of Medical Sciences, Jining, China
| | - Xiaodan Huang
- Shandong Institute of Parasitic Diseases, Shandong First Medical University & Shandong Academy of Medical Sciences, Jining, China
| | - Hongmei Liu
- Shandong Institute of Parasitic Diseases, Shandong First Medical University & Shandong Academy of Medical Sciences, Jining, China
| | - Lijuan Liu
- Shandong Institute of Parasitic Diseases, Shandong First Medical University & Shandong Academy of Medical Sciences, Jining, China
| | - Xiuxia Guo
- Shandong Institute of Parasitic Diseases, Shandong First Medical University & Shandong Academy of Medical Sciences, Jining, China
| | - Chongxing Zhang
- Shandong Institute of Parasitic Diseases, Shandong First Medical University & Shandong Academy of Medical Sciences, Jining, China
| | - Yuqiang Zhao
- Shandong Institute of Parasitic Diseases, Shandong First Medical University & Shandong Academy of Medical Sciences, Jining, China
| | - Jingxuan Kou
- School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, China
| | - Huaiwei Wang
- Shandong Institute of Parasitic Diseases, Shandong First Medical University & Shandong Academy of Medical Sciences, Jining, China
| | - Peng Cheng
- Shandong Institute of Parasitic Diseases, Shandong First Medical University & Shandong Academy of Medical Sciences, Jining, China
| | - Maoqing Gong
- Shandong Institute of Parasitic Diseases, Shandong First Medical University & Shandong Academy of Medical Sciences, Jining, China
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Bush PA, Pereira KC. Old Drugs, New Concerns. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2020.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Leshem E. Antibiotics for travelers' diarrhea in children?: To SBET or not to SBET? Travel Med Infect Dis 2020; 34:101681. [DOI: 10.1016/j.tmaid.2020.101681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 04/16/2020] [Accepted: 04/16/2020] [Indexed: 01/12/2023]
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Murphy H, Bodhidatta L, Sornsakrin S, Khadka B, Pokhrel A, Shakya S, Suksawad U, Wongstitwilairoong B, Shrestha S, Mason C, Pandey P. Traveler's diarrhea in Nepal-changes in etiology and antimicrobial resistance. J Travel Med 2019; 26:5537693. [PMID: 31355414 DOI: 10.1093/jtm/taz054] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/13/2019] [Accepted: 07/17/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND We conducted a comprehensive investigation to update our knowledge of traveler's diarrhea (TD) etiology and antimicrobial resistance (AMR) in Nepal. METHODS A case-control study of TD etiology was conducted at the CIWEC Clinic Travel Medicine Center in Kathmandu from 2012 to 2014. Stool samples were tested by microscopy, culture and molecular techniques for identification of bacterial, viral and parasitic enteric pathogens, and AMR. We analysed patient demographic data, pre-treatment information and clinical outcomes. RESULTS We enrolled 433 TD cases and 209 non-diarrhea controls. At least one of enteric pathogens was identified among 82% of cases and 44% of controls (P < 0.001). Multiple pathogens were observed among 35% of cases and 10% of controls. The most common pathogens significantly identified among cases in comparison with controls were Campylobacter (20%), norovirus (17%), enterotoxigenic E. coli (ETEC) (12%), rotavirus (9%) and Shigella (8%) (P < 0.001). We noted Campylobacter, Shigella and ETEC resistance to azithromycin at 8, 39 and 22% and to ciprofloxacin at 97, 78 and 23%, respectively. CONCLUSION Among travellers to Nepal with TD, viral pathogens were commonly found and norovirus was the second most common pathogen after campylobacter. We noted increased AMR to fluoroquinolones (FQs) and azithromycin (AZM). There is heightened concern for AZM treatment failures, though this continues to remain the drug of choice for TD treatment in our setting where FQs should not be used.
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Affiliation(s)
- Holly Murphy
- IHA Infectious Diseases Consultants, 5333 McAuley Dr., Ypsilanti, MI, USA
| | - Ladaporn Bodhidatta
- Department of Enteric Diseases, Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand
| | - Siriporn Sornsakrin
- Department of Enteric Diseases, Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand
| | | | | | | | - Umaporn Suksawad
- Department of Enteric Diseases, Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand
| | - Boonchai Wongstitwilairoong
- Department of Enteric Diseases, Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand
| | - Sanjaya Shrestha
- Walter Reed/AFRIMS Research Unit Nepal (WARUN), Kathmandu, Nepal
| | - Carl Mason
- Henry M. Jackson Foundation, Bethesda, MD, USA
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Abstract
Athletes are susceptible to many acute illnesses that can interfere with their ability to train and compete as well as potentially affecting teammates and coaching staff. A solid understanding of the preventive measures, diagnosis, and management of such diseases is paramount in the care of an athletic population.
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Affiliation(s)
- Carrie A Jaworski
- Division of Primary Care Sports Medicine, NorthShore University HealthSystem, Glenview, IL, USA; Department of Family Medicine, University of Chicago, Pritzker School of Medicine, Chicago, IL, USA.
| | - Valerie Rygiel
- Primary Care Sports Medicine Fellowship, University of Chicago/NorthShore University HealthSystem, 2180 Pfingsten Road, Suite 3100, Glenview, IL 60026, USA
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Santacroce L, Charitos IA, Bottalico L. A successful history: probiotics and their potential as antimicrobials. Expert Rev Anti Infect Ther 2019; 17:635-645. [PMID: 31318576 DOI: 10.1080/14787210.2019.1645597] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: Probiotics are living, non-pathogenic microorganisms (bacteria) that enter through diet in the human body, live during their passage through the gastrointestinal (GI) tract and are beneficial to health. They have become popular in recent years as a way of improving human health through nutrition. This review aims to discuss the efficacy of probiotics for the supportive therapy of certain clinical conditions, especially infectious diseases, as reported in a number of studies, even though some concerns about their safety still remain. Areas covered: This paper will review the history of probiotics, from ancient ages to date, and the evolution of their use in clinical practice. The study is based on both personal professional experience of the authors and a comprehensive literature analysis, including old documents from libraries, searching the related biological and clinical data on Scopus, Web of Science, PubMed, EMBASE, also using the 'cited by' and 'similar articles' options available in PubMed. Expert opinion: Not all researchers agree about the safety and real efficacy of probiotics in common conditions, especially infective diseases. However, the use of probiotics for clinical conditions that may be improved by consumption of these dietary supplements should be considered as a possible supportive therapy in select patients.
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Affiliation(s)
- Luigi Santacroce
- a Ionian Department (DJSGEM), Microbiology and Virology Laboratory, University of Bari , Bari , Italy
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Kohl SE, Barnett ED. What do we know about travel for children with special health care needs? A review of the literature. Travel Med Infect Dis 2019; 34:101438. [PMID: 31233860 DOI: 10.1016/j.tmaid.2019.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 06/19/2019] [Accepted: 06/20/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Children travel with their families, including children with chronic illness. We know that adults with chronic illness who travel are more likely than their healthy peers to become sick while traveling. A review of the literature was undertaken to identify what is known about traveling with children with special health care needs and to identify gaps in our knowledge. METHODS An Online search of the PubMed, CINAHL and Google databases of English language literature was conducted June 2016, October 2017, June 2018 and April 2019 using the terms children and travel, air travel, travel health, disabled child, children with special healthcare needs, parents of disabled children, vacations, recreation, international, wheelchairs, planning techniques, asthma, diabetes, altitude, cystic fibrosis, inflammatory bowel disease, sickle cell disease, depression, food allergies, Attention Deficit Hyperactivity Disorder (ADHD), and seizures. The search was limited to years 2000-2019. A secondary search of relevant articles was conducted using the reference sections of articles identified in the primary search. RESULTS 185 papers were examined for travel health related outcomes for children and adults with chronic diseases. Articles were excluded if they addressed the educational needs of students with disabilities traveling abroad, did not directly address travel health (e.g travel skills, travel itineraries), contained outdated policy statements, or were case reports of a single patient. The remaining 84 papers were organized and reviewed by organ systems. The articles were primarily descriptive and did not lend themselves to a systematic review. CONCLUSION Children traveling with chronic and complex health conditions are a heterogeneous group of vulnerable travelers. Closing the knowledge gap about how to best help these travelers requires a multipronged approach. Research is urgently needed to identify best practices for five of the most common chronic childhood diseases: asthma, depression, ADHD, food allergies and autism. For less common illnesses, ones typically cared for in specialty clinics, expert consensus opinion and multi-center studies are needed. Families and disease advocacy societies should be included in the research as they may have already identified the most pressing travel-related health concerns and solutions for these problems.
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Affiliation(s)
- Sarah E Kohl
- University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA, 15213, USA.
| | - Elizabeth D Barnett
- Boston University School of Medicine, 72 East Concord Street, Boston, MA, 02118, USA
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Ericsson CD, Connor BA, Riddle MS. When should travel medicine practitioners prescribe Rifamycin SV-MXX for self-treatment of travellers' diarrhoea? J Travel Med 2019; 26:5372334. [PMID: 30848819 DOI: 10.1093/jtm/taz013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 03/05/2019] [Indexed: 01/06/2023]
Affiliation(s)
| | - Bradley A Connor
- Weill Cornell Medical College and the New York Center for Travel and Tropical Medicine, New York, NY, USA
| | - Mark S Riddle
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Bonham CT, Pallett SJC, Holland TJ. OP TRENTON 3: An analysis of primary care presentations to a deployed role 1 in support of a United Nation peacekeeping operation. J ROY ARMY MED CORPS 2019; 167:310-315. [PMID: 31036748 DOI: 10.1136/jramc-2019-001203] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 03/25/2019] [Accepted: 03/28/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Health data of operational relevance from South Sudan are lacking, outdated and non-representative. This study sets out to record and analyse primary healthcare (PHC) presentations to a deployed UK Level 1 Primary Healthcare Centre (L1 PHC) facility in Bentiu, South Sudan, to inform on disease prevalence for UK Military Personnel in a sub-Saharan Operational environment. METHODS A prospective single-centre cohort study was completed for all PHC presentations to a UK L1 PHC facility while deployed on the United Nations Mission to South Sudan from June 2017 to November 2017. RESULTS 861 episodes of clinical care were recorded at Bentiu Camp during the 6-month period. 82% were from disease; 18% non-battle injuries and no battle injuries were seen. As per EPINATO2 categorisation, the top three presentations were acute gastrointestinal disease, dermatological disease and routine clinical care. Differences were noted for June-August and September-November, as a proportion of total cases seen. It was noted that gastrointestinal illnesses were three times more likely in the first half of the operation and bites and sting almost twice as likely. CONCLUSIONS Gastrointestinal disease results in a significant burden on humanitarian operations where an extended Relief-in-Place is a key area of risk. The EPINATO2 reporting tool provides insufficient detail for planning purposes and an improved method of data collection is required. Targeting the diagnosis and management of infectious diseases during predeployment training should prepare L1 PHC for the most common cases encountered. Delivery of targeted Force Health Protection training for all personnel with early deployment of L1 PHC forward could improve support to commanders during the highest risk periods.
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Bourque DL, Solomon DA, Sax PE. Health Considerations for HIV-Infected International Travelers. Curr Infect Dis Rep 2019; 21:16. [PMID: 30980287 DOI: 10.1007/s11908-019-0672-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF THE REVIEW International travel continues to steadily increase, including leisure travel, travel to one's country of origin to visit friends and relatives, travel for service work, and business travel. Travelers with HIV may have an increased risk for travel-associated infections. The pre-travel medical consultation is an important means of assessing one's risk for travel-related health issues. The aim of this review is to provide an update on key health considerations for the HIV-infected traveler. RECENT FINDINGS Like all travelers, the HIV-infected traveler should adhere to behavioral precautions, including safety measures with food and water consumption, safe sexual practices, and arthropod bite avoidance. HIV is a risk factor for venous thromboembolism and patients should be educated regarding this risk. Most pre-travel vaccines are safe and immunogenic in HIV-infected individuals, though live vaccines should be avoided in patients with low CD4 counts. Malaria chemoprophylaxis is strongly recommended in patients with HIV traveling to endemic areas and no significant interactions exist between the commonly used prophylactic anti-malarial agents and anti-retroviral therapy (ART). Travelers with HIV, particularly those who are not on ART or who have low CD4 cell counts, may have increased risk for tuberculosis, malaria, enteric infections, visceral leishmaniasis, American trypanosomiasis, and endemic mycoses such as histoplasmosis, talaromycosis, and coccidioidomycosis. The immune status of the HIV-infected traveler should be assessed prior to travel along with the duration, itinerary, and activities planned during travel in order to carefully consider individual risk for travel-related health issues.
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Affiliation(s)
- Daniel L Bourque
- Division of Infectious Diseases and Travel Medicine, Mount Auburn Hospital, Cambridge, MA, USA. .,Harvard Medical School, Boston, MA, USA.
| | - Daniel A Solomon
- Harvard Medical School, Boston, MA, USA. .,Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA.
| | - Paul E Sax
- Harvard Medical School, Boston, MA, USA. .,Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA.
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Wang Y, Wang X, Liu X, Ren R, Zhou L, Li C, Tu W, Ni D, Li Q, Feng Z, Zhang Y. Epidemiology of Imported Infectious Diseases, China, 2005-2016. Emerg Infect Dis 2019; 25:33-41. [PMID: 30560778 PMCID: PMC6302593 DOI: 10.3201/eid2501.180178] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Imported infectious diseases are becoming a serious public health threat in China. However, limited information concerning the epidemiologic characteristics of imported infectious diseases is available. In this study, we collected data related to imported infectious diseases in mainland China from the National Information Reporting System of Infectious Diseases and analyzed demographic, temporal, and spatial distributions. The number of types of imported infectious diseases reported increased from 2 in 2005 to 11 in 2016. A total of 31,740 cases of infectious disease were imported to mainland China during 2005–2016; most of them were found in Yunnan Province. The cases were imported mainly from Africa and Asia. As a key and effective measure, pretravel education should be strengthened for all migrant workers and tourists in China, and border screening, cross-border international cooperation, and early warning should be further improved.
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Epidemiology and etiology of diarrhea in UK military personnel serving on the United Nations Mission in South Sudan in 2017: A prospective cohort study. Travel Med Infect Dis 2019; 28:34-40. [DOI: 10.1016/j.tmaid.2018.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/10/2018] [Accepted: 12/11/2018] [Indexed: 02/07/2023]
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Exercise-Induced Illness and Inflammation: Can Immunonutrition and Iron Help? Int J Sport Nutr Exerc Metab 2019; 29:181-188. [PMID: 30507260 DOI: 10.1123/ijsnem.2018-0288] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The main focus of this review is illness among elite athletes, how and why it occurs, and whether any measures can be taken to combat it or to prevent its onset. In particular, there is particular interest in exercise-induced immunodepression, which is a result of the immune system regarding exercise (e.g., prolonged, exhaustive exercise) as a challenge to its function. This promotes the inflammatory response. There is often a high incidence of illness in athletes after undertaking strenuous exercise, particularly among those competing in endurance events, not only mainly in terms of upper respiratory tract illness, but also involving gastrointestinal problems. It may well be that this high incidence is largely due to insufficient recovery time being allowed after, for example, a marathon, a triathlon, or other endurance events. Two examples of the incidence of upper respiratory tract illness in moderate versus endurance exercise are provided. In recent years, increasing numbers of research studies have investigated the origins, symptoms, and incidence of these bouts of illness and have attempted to alleviate the symptoms with supplements, sports foods, or immunonutrition. One aspect of the present review discusses iron deficiency, which has been primarily suggested to have an impact upon cell-mediated immunity. Immunonutrition is also discussed, as are new techniques for investigating links between metabolism and immune function.
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Guiral E, Gonçalves Quiles M, Muñoz L, Moreno-Morales J, Alejo-Cancho I, Salvador P, Alvarez-Martinez MJ, Marco F, Vila J. Emergence of Resistance to Quinolones and β-Lactam Antibiotics in Enteroaggregative and Enterotoxigenic Escherichia coli Causing Traveler's Diarrhea. Antimicrob Agents Chemother 2019; 63:e01745-18. [PMID: 30478165 PMCID: PMC6355616 DOI: 10.1128/aac.01745-18] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 11/16/2018] [Indexed: 12/15/2022] Open
Abstract
The objective of this study was to assess the antimicrobial resistance of enteroaggregative Escherichia coli (EAEC) and enterotoxigenic E. coli (ETEC) strains causing traveler's diarrhea (TD) and to investigate the molecular characterization of antimicrobial resistance genes to third-generation cephalosporins, cephamycins, and quinolones. Overall, 39 EAEC and 43 ETEC clinical isolates were studied. The susceptibilities of EAEC and ETEC against ampicillin, amoxicillin-clavulanic acid, cefotaxime, imipenem, chloramphenicol, tetracycline, co-trimoxazole, nalidixic acid, ciprofloxacin, azithromycin, and rifaximin were determined. All genes encoding resistance determinants were detected by PCR or PCR plus DNA sequencing. The epidemiology of selected EAEC and ETEC strains was studied using multilocus sequence typing (MLST). The resistance to quinolones of EAEC and ETEC strains causing TD has significantly increased over the last decades, and high percentages have been found especially in patients traveling to India and sub-Saharan Africa. Sequence type 38 (ST38) and ST131, carrying the blaCTX-M-15 and blaCTX-M-27 genes, respectively, are highly prevalent among extended-spectrum β-lactamase (ESBL)-producing EAEC and ETEC strains. The cephamycinase ACT-20 is described in the present study for the first time in EAEC and ETEC strains causing TD in patients who had traveled to Central America. The percentages of resistance to azithromycin in EAEC and ETEC isolates from patients to Southeast Asia/India and Africa are above 25%. Meanwhile, rifaximin is still active against EAEC and ETEC, with the prevalence of resistant strains not being high. In conclusion, fluoroquinolones should no longer be considered the drugs of choice for the prevention or treatment in TD for travelers traveling to India and Africa. Azithromycin and rifaximin are still a good alternative to treat TD caused by EAEC or ETEC.
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Affiliation(s)
| | | | - Laura Muñoz
- Institute of Global Health of Barcelona, Barcelona, Spain
| | | | - Izaskun Alejo-Cancho
- Department of Clinical Microbiology, Hospital Clinic, School of Medicine, University of Barcelona, Barcelona, Spain
| | - Pilar Salvador
- Department of Clinical Microbiology, Hospital Clinic, School of Medicine, University of Barcelona, Barcelona, Spain
| | - Miriam J Alvarez-Martinez
- Institute of Global Health of Barcelona, Barcelona, Spain
- Department of Clinical Microbiology, Hospital Clinic, School of Medicine, University of Barcelona, Barcelona, Spain
| | - Francesc Marco
- Institute of Global Health of Barcelona, Barcelona, Spain
- Department of Clinical Microbiology, Hospital Clinic, School of Medicine, University of Barcelona, Barcelona, Spain
| | - Jordi Vila
- Institute of Global Health of Barcelona, Barcelona, Spain
- Department of Clinical Microbiology, Hospital Clinic, School of Medicine, University of Barcelona, Barcelona, Spain
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Suryapranata F, Boyd A, Grobusch MP, Prins M, Sonder G. Symptoms of infectious diseases in HIV-positive travellers: A prospective study with exposure-matched controls. Travel Med Infect Dis 2019; 29:28-33. [PMID: 30641130 DOI: 10.1016/j.tmaid.2019.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 01/06/2019] [Accepted: 01/07/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Recently, the number of HIV-infected travellers to (sub)tropical areas has increased substantially. In the Netherlands, HIV-positive travellers with CD4-cells of <500/mm3 are advised to carry stand-by antibiotic treatment against travellers' diarrhoea. Our aim was to determine whether HIV infection is associated with travel-related symptomatic diseases. METHODS A prospective study was performed among HIV-infected travellers and age-matched HIV-uninfected travel companions serving as controls, attending two travel clinics in Amsterdam. Participants filled out daily questionnaires before, during, and after their trip. RESULTS Overall, 52 pairs were included. All participants were male, and 91.3% were born in a Western country. Prevalence of travel-related diarrhoea was 50% among HIV-positive travellers and 40% among controls. No significant differences were observed for incident travel-related diarrhoea (incidence rate ratio = 1.60, 95%CI = 0.79-3.27) or duration of symptoms (odds ratio = 1.49, 95%CI = 0.65-3.45). There were no significant differences in symptom incidence or duration for travel-related vomiting, cough, rhinitis, pruritus, fatigue, or nausea. Only 6.3% of HIV-positive travellers with CD4-cells of <500/mm3 and diarrhoea used their stand-by antibiotic treatment as recommended. CONCLUSION Travel-related symptoms were not significantly more frequent or longer lasting among HIV-infected travellers compared to controls. Most HIV-infected travellers with CD4-cells of <500/mm3 and diarrhoea did not take stand-by antibiotic treatment. These results may question the need for routine prescription of stand-by antibiotics among this specific risk group. Further research, especially among HIV infected VFR travellers and in larger study groups is needed.
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Affiliation(s)
- Franciska Suryapranata
- Department of Infectious Diseases, Public Health Service (GGD) of Amsterdam, Amsterdam, the Netherlands; National Coordination Centre for Travellers' Health Advice (LCR), Amsterdam, the Netherlands.
| | - Anders Boyd
- Department of Infectious Diseases, Public Health Service (GGD) of Amsterdam, Amsterdam, the Netherlands; INSERM, UMR S1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
| | - Martin P Grobusch
- Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, Amsterdam Infection & Immunity Institute (AIII), University of Amsterdam, the Netherlands
| | - Maria Prins
- Department of Infectious Diseases, Public Health Service (GGD) of Amsterdam, Amsterdam, the Netherlands; Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, Amsterdam Infection & Immunity Institute (AIII), University of Amsterdam, the Netherlands
| | - Gerard Sonder
- Department of Infectious Diseases, Public Health Service (GGD) of Amsterdam, Amsterdam, the Netherlands; National Coordination Centre for Travellers' Health Advice (LCR), Amsterdam, the Netherlands; Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, Amsterdam Infection & Immunity Institute (AIII), University of Amsterdam, the Netherlands
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Traveler's Diarrhea Recommendations for Solid Organ Transplant Recipients and Donors. Transplantation 2018; 102:S35-S41. [PMID: 29381576 DOI: 10.1097/tp.0000000000002015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Antibiotic resistance, molecular characterizations, and clinical manifestations of Campylobacteriosis at a military medical center in Hawaii from 2012-2016: a retrospective analysis. Sci Rep 2018; 8:11736. [PMID: 30082843 PMCID: PMC6078982 DOI: 10.1038/s41598-018-29461-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 06/28/2018] [Indexed: 01/20/2023] Open
Abstract
Hawaii has one of the highest incidences of Campylobacteriosis in the United States, but there remains little published data on circulating strains or antimicrobial resistance. We characterized 110 clinical Campylobacter isolates (106 C. jejuni, 4 C. coli) processed at Tripler Army Medical Center in Honolulu, HI from 2012–2016. Twenty-five percent of C. jejuni isolates exhibited fluoroquinolone (FQ) resistance, compared with 16% for tetracycline (TET), and 0% for macrolides. Two of the four C. coli isolates were resistant to FQ, TET, and macrolides. C. jejuni isolates further underwent multilocus sequence typing, pulsed-field gel electrophoresis, and molecular capsular typing. Nineteen capsule types were observed, with two capsule types (HS2 and HS9) being associated with FQ resistance (p < 0.001 and p = 0.006, respectively). HS2 FQ-resistant isolates associated with clonal complex 21, possibly indicating clonal spread in FQ resistance. Macrolides should be considered for treatment of suspect cases due to lack of observed resistance.
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Rodrigues KMDP, Moreira BM. Preventing diseases in round-the-world travelers: a contemporary challenge for travel medicine advice. Rev Soc Bras Med Trop 2018; 51:125-132. [PMID: 29768543 DOI: 10.1590/0037-8682-0418-2017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 03/27/2018] [Indexed: 11/22/2022] Open
Abstract
Providing advice for travelers embarking on long-term trips poses a challenge in travel medicine. A long duration of risk exposure is associated with underuse of protective measures and poor adherence to chemoprophylaxis, increasing the chances of acquiring infections. Recently, in our clinic, we observed an increase in the number of travelers undertaking round-the-world trips. These individuals are typically aged around 32 years and quit their jobs to embark on one-to-two-year journeys. Their destinations include countries in two or more continents, invariably Southeast Asia and Indonesia, and mostly involve land travel and visiting rural areas. Such trips involve flexible plans, increasing the challenge, especially with regard to malaria prophylaxis. Advising round-the-world travelers is time-consuming because of the amount of information that must be provided to the traveler. Advisors must develop strategies to commit the traveler to his/her own health, and verify their learnings on disease-prevention measures. Contacting the advisor after the appointment or during the trip can be helpful to clarify unclear instructions or diagnosis made and prescriptions given abroad. Infectious diseases are among the most frequent problems affecting travelers, many of which are preventable by vaccines, medicines, and precautionary measures. The dissemination of counterfeit medicines, particularly antibiotics and antimalarial medicines, emphasizes the need for travelers to carry medicines that they may possibly need on their trip. Additional advice on altitude, scuba diving, and other possible risks may also be given. Considering the difficulties in advising this group, we present a review of the main recommendations on advising these travelers.
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Affiliation(s)
- Karis Maria de Pinho Rodrigues
- Departamento de Medicina Preventiva, Centro de Informação em Saúde para Viajantes (Cives), Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Beatriz Meurer Moreira
- Instituto de Microbiologia Paulo de Goés, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
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Lääveri T, Vilkman K, Pakkanen S, Kirveskari J, Kantele A. Despite antibiotic treatment of travellers' diarrhoea, pathogens are found in stools from half of travellers at return. Travel Med Infect Dis 2018; 23:49-55. [PMID: 29702254 DOI: 10.1016/j.tmaid.2018.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 03/24/2018] [Accepted: 04/09/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Among visitors to the (sub)tropics, 20-50% contract travellers' diarrhoea (TD) and 5-30% take antibiotics. While shortening the duration of illness, antimicrobials predispose to acquisition of multi-drug resistant bacteria. Therefore, liberal use is no longer advocated. Although antibiotics kill pathogens, no data support the view that they could prevent post-infectious sequelae. We investigated how antibiotic use for TD abroad impacts the pathogen findings at return. MATERIALS AND METHODS We revisited 456 travellers' clinical data and stool pathogens examined by qPCR for Salmonella, Yersinia, Campylobacter, Shigella, Vibrio cholerae and enteroaggregative (EAEC), enteropathogenic (EPEC), enterotoxigenic (ETEC), enterohaemorrhagic (EHEC) and enteroinvasive (EIEC) Escherichia coli. RESULTS Among travellers with TD, antibiotic users had pathogen-positive samples less frequently than non-users (50% versus 83%). The difference was significant for EPEC (23% versus 47%) and EAEC (27% versus 54%), but not ETEC (17% versus 26%) or the other pathogens. Shigella/EIEC was found more often among antibiotic users than non-users (4% versus 1%). CONCLUSION Despite antibiotic treatment of TD, half of the users still had stool pathogens at return, reflecting either antibiotic resistance of pathogens or recolonisation/reinfection while abroad. Treatment of TD with antibiotics during travel should not be interpreted to indicate eradication of pathogens.
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Affiliation(s)
- Tinja Lääveri
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland, POB 348, FIN-00029 HUS, Finland.
| | - Katri Vilkman
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland, POB 348, FIN-00029 HUS, Finland.
| | - Sari Pakkanen
- Department of Bacteriology and Immunology, University of Helsinki, Helsinki, Finland, POB 21, FIN-00014 Helsinki, Finland.
| | - Juha Kirveskari
- Helsinki University Hospital Laboratory (HUSLAB), Department of Bacteriology, Helsinki, Finland, POB 720, FIN-00029 HUS, Finland; Mobidiag Ltd, Espoo, Finland, Keilaranta 16 A, FIN-02150 Espoo Finland.
| | - Anu Kantele
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland, POB 348, FIN-00029 HUS, Finland; Clinicum, University of Helsinki, Helsinki, Finland, POB 63, FI-00014 Helsinki, Finland; Aava Travel Clinic, Medical Centre Aava, Helsinki, Finland, Annankatu 32, FIN-00100 Helsinki, Finland; Unit of Infectious Diseases, Department of Medicine/Solna, Karolinska Institutet, Stockholm, Sweden, SE-17176 Stockholm, Sweden.
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