Enteric pathogens in Mexican sauces of popular restaurants in Guadalajara, Mexico, and Houston, Texas

Distribution and virulence of Escherichia coli harboring cyclomodulins and supplementary virulence genes isolates from clinical and environmental samples

This study aimed to determine the prevalence of cyclomodulins (cdt, cnf, pks and cif) in Escherichia coli (E. coli) isolated from clinical and environmental samples, the presence of supplementary virulence genes (SVG), antibiotic resistance, and in vitro cytotoxicity. 413 E. coli were isolated from clinical (stool from obese subjects, normal weight subjects, children with diarrhea, and children without diarrhea; and urine from pregnant and non-pregnant women with urinary tract infections) and environmental (water and different foods) samples. PCR was performed to identify E. coli pathotypes, the four cyclomodulins, and 18 SVG; virulence score, cytotoxic assay, and antibiotic resistance assay were performed. Fifteen percent of E. coli were positive for cyclomodulins and were found in all isolation sources; however, in children with diarrhea, they were more frequent. The most frequent cyclomodulin was cdt. More DEC strains harbor cyclomodulins than non-DEC, and cyclomodulins were most frequent among aEPEC pathotype. SVG ehaC was associated with cyclomodulin-positive strains. Cyclomodulin-positive E. coli had a higher virulence score but no significant cytotoxic activity. They were slightly more resistant to antibiotics. In conclusion, cyclomodulins-positive E. coli was widely distributed in humans, food, and the environment, and they were associated with SVG ehaC, suggesting that these genes may play a role in the pathogenesis of the cyclomodulins. However, more research is needed.

Dielectric properties of Mexican sauces for microwave-assisted pasteurization process

The dielectric properties and specifically the complex relative permittivity of foods are key elements for the design of pasteurization processes with high frequency electromagnetic waves. Mexican sauces are recognized worldwide for their flavor and nutritional properties. In this work, the complex permittivity of four of the most representative sauces of Mexican cuisine (chipotle chili, habanero chili, red and green sauce) is presented. The permittivity was measured with the open coaxial probe method at temperatures of 25, 40, 55, 70, 85 °C and in the frequency range of 500 MHz to 6 GHz. Additionally, moisture content, specific heat, viscosity, water activity, density and electrical conductivity are reported, these last three at 25 °C. Dielectric properties were affected by the sauce formulation. The loss factor of each sauce sample at any temperature presents significant changes in relation to the frequency. At 915 and 2,450 MHz, d ε ' ' d T > 0 , which would cause a thermal runaway effect or the uncontrolled rise in temperature in the sauces during the microwave pasteurization. At 5,800 MHz, d ε ' ' d T < 0 , which would give better control for microwave heating than at 915 and 2,450 MHz. At 915 MHz, the loss factor of all sauces is higher than at 2,450 and 5,800 MHz, therefore, more rapid heating can be produced. Moreover, at 915 MHz, microwaves exhibit higher penetration depth than at 2,450 and 5,800 MHz; therefore, at 915 MHz, the greatest uniform microwave dielectric heating would be achieved. Thus, 915 MHz is the frequency recommended for the studied sauces pasteurization. PRACTICAL APPLICATION: This work provides the dielectric properties of Mexican sauces at different temperatures and their penetration depths in the microwave range, which are key information for further microwave-assisted pasteurization process and for getting safer sauces for consumers. Moreover, this research supplies suggestions about what frequency for ISM (Industrial, Scientific and Medical) applications is the best for microwave-assisted pasteurization according to the penetration depth of the electromagnetic wave in the sauces and microwave dielectric heating speed of the sauces.

Hibiscus Acid and Chromatographic Fractions from Hibiscus Sabdariffa Calyces: Antimicrobial Activity against Multidrug-Resistant Pathogenic Bacteria

The anti-microbial properties of acetone extracts from Hibiscus sabdariffa calyces, fractions isolated by silica gel chromatography and hibiscus acid purified from some of these fractions and additionally identified by nuclear magnetic resonance spectroscopy, mid-infrared spectroscopy and X-ray diffraction, were studied against both multidrug-resistant Salmonella strains and pathogenic Escherichia coli bacteria. Gel diffusion was used to determine the anti-microbial effects. The mode of action of hibiscus acid was determined by crystal violet assay. Hibiscus acid and 17 of the 25 chromatographic fractions obtained, displayed an anti-microbial effect against all bacterial strains tested. Hibiscus acid showed a greater anti-microbial effect than the acetone extract against most of the bacteria strains, while chromatographic fractions IX–XIV exerted the greatest anti-microbial effect against all bacteria. The minimum inhibitory concentration of the acetone extract was 7 mg/mL, and the minimum bactericidal concentration was 10 mg/mL, while the corresponding values for hibiscus acid were 4–7 and 7 mg/mL, respectively. The results of the crystal violet assay indicate that hibiscus acid alters membrane permeability. Hibiscus acid is a potential alternative to control multidrug-resistant bacteria. Due to its ready availability and easy extraction from H. sabdariffa, hibiscus acid is potentially useful in the food industries.

Soil-transmitted helminthiases in Nepal: Transmission boundaries and implications for local communities and international travelers

Soil transmitted helminthiasis (STHs) are endemic in Nepal but since the country territory is extremely heterogeneous, a multidisciplinary assessment is required to evaluate the risk of infection in different areas. Prevalence data were retrieved with systematic literature search and geographical coordinates were assigned to each survey site. Spatial stratification was then implemented considering land use and ecological parameters. STH transmission boundaries were tested after reference criteria and elevation was evaluated as additional predictor: the elevation threshold of 3057 m above sea level is demarking the STH transmission limit. Areas above this threshold are safe, but since lodging in at-risk sites is a compulsory stopover for international travelers, STH risk exposure should be considered for every travel to the country.

The elite athlete as a special risk traveler and the jet lag's effect: lessons learned from the past and how to be prepared for the next Olympic Games 2020 Tokyo

BACKGROUND

Elite athletes have to travel long-haul distances and cross multiple meridians; thus, a unique syndrome named as jet-lag is induced. Furthermore, traveler athletes are submitted to several factors negatively affecting their well-being and athletic performance. This qualitative descriptive study aims to promote safely and future promising participations of elite athletes in great events, such as the next Olympic Games 2020 Tokyo, based on the chronobiology of jet-lag, factors affecting the traveler athlete and previous experiences from the 2014 FIFA World Cup Brazil, the 2018 FIFA World Cup Russia and the Olympic Games Rio 2016.

METHODS

A narrative review of the literature across a broad cross-section of the chronobiology of jet-lag and factors affecting the traveler athlete was undertaken. In addition, a general analysis based on the past sport events aforementioned is also included.

RESULTS

The jet-lag disorder may occur after transmeridian travel over more than three time-zones and the resynchronization is dependent on the direction and number of the time-zones crossed and the availability and the intensity of local circadian time cues. Also the athlete's ability to sleep, eat, get hydrated and train, are essential, as well as, others individual tolerance differences, such as age, gender, chronotype and ethnic differences. Athletes should arrive a number of days before the competition according to the number of time-zone transitions experienced.

CONCLUSIONS

Jet-lag is usually benign and self-limited, but can occasionally have serious consequences for the athlete's mental and physical health and performance. A good plan concerning the athlete's traveling schedule, sleeping, eating and training before and after travelling is mandatory.

Prevalence, antimicrobial resistance and virulence genes of Escherichia coli isolated from retail meat in Tamaulipas, Mexico

OBJECTIVES

The aim of this study was to determinate the prevalence of Escherichia coli and its resistance to antimicrobials and the presence of virulence genes in retail samples of beef and pork in several locations in Tamaulipas, Mexico.

METHODS

A total of 106 samples (54 beef and 52 pork) collected from August 2013 to March 2014 were analysed to detect E. coli isolates. The E. coli isolates were then analysed for detection of virulence factors and antimicrobial resistance genes. Antimicrobial susceptibility to 16 antimicrobial agents was also determined.

RESULTS

A total of 158 E. coli isolates were obtained, among which 3 (1.9%) harboured the virulence gene stx1, 28 (17.7%) harboured stx2 and 34 (21.5%) harboured hlyA. High phenotypic resistance was observed in almost all isolates, since 146 (92.4%) showed a multiresistant phenotype with resistance to cefalotin (92%), ampicillin (92%), cefotaxime (78%), nitrofurantoin (76%) and tetracycline (75%). The antimicrobial resistance genes tet(A) and tet(B) were detected in 56% of isolates, strA in 9.6%, aadA in 17% and aac(3)-IV in only 0.6% of strains.

CONCLUSIONS

Based on these results, it can be concluded that retail beef and pork meat may play a role in the spread of antimicrobial-resistant E. coli strains in this region.

Diarrheagenic Escherichia coli

Most Escherichia coli strains live harmlessly in the intestines and rarely cause disease in healthy individuals. Nonetheless, a number of pathogenic strains can cause diarrhea or extraintestinal diseases both in healthy and immunocompromised individuals. Diarrheal illnesses are a severe public health problem and a major cause of morbidity and mortality in infants and young children, especially in developing countries. E. coli strains that cause diarrhea have evolved by acquiring, through horizontal gene transfer, a particular set of characteristics that have successfully persisted in the host. According to the group of virulence determinants acquired, specific combinations were formed determining the currently known E. coli pathotypes, which are collectively known as diarrheagenic E. coli. In this review, we have gathered information on current definitions, serotypes, lineages, virulence mechanisms, epidemiology, and diagnosis of the major diarrheagenic E. coli pathotypes.

Murine immunization with CS21 pili or LngA major subunit of enterotoxigenic Escherichia coli (ETEC) elicits systemic and mucosal immune responses and inhibits ETEC gut colonization

CS21 pili of enterotoxigenic Escherichia coli (ETEC) is one of the most prevalent ETEC colonization factors. CS21 major subunit, LngA, mediates ETEC adherence to intestinal cells, and contributes to ETEC pathogenesis in a neonatal mouse infection model. The objectives of this work were to evaluate LngA major subunit purified protein and CS21 purified pili on immunogenicity and protection against ETEC colonization of mice intestine. Recombinant LngA purified protein or purified CS21 pili from E9034A ETEC strain were evaluated for immunogenicity after immunization of C57BL/6 mice. Specific anti-LngA antibodies were detected from mice serum, feces, and intestine fluid samples by ELISA assays. Protection against gut colonization was evaluated on immunized mice orally challenged with wild type E9034A ETEC strain and by subsequent quantification of bacterial colony forming units (CFU) recovered from feces. Recombinant LngA protein and CS21 pili induced specific humoral and mucosal anti-LngA antibodies in the mouse model. CS21 combined with CT delivered intranasally as well as LngA combined with incomplete Freund adjuvant delivered intraperitoneally inhibited ETEC gut colonization in a mouse model. In conclusion, both LngA purified protein and CS21 pili from ETEC are highly immunogenic and may inhibit ETEC intestinal shedding. Our data on immunogenicity and immunoprotection indicates that CS21 is a suitable vaccine candidate for a future multivalent vaccine against ETEC diarrhea.

Behavior of shiga toxin-producing Escherichia coli, enteroinvasive E. coli, enteropathogenic E. coli and enterotoxigenic E. coli strains on whole and sliced jalapeño and serrano peppers

The behavior of enterotoxigenic Escherichia coli (ETEC), enteropathogenic E. coli (EPEC), enteroinvasive E. coli (EIEC) and non-O157 shiga toxin-producing E. coli (non-O157-STEC) on whole and slices of jalapeño and serrano peppers as well as in blended sauce at 25 ± 2 °C and 3 ± 2 °C was investigated. Chili peppers were collected from markets of Pachuca city, Hidalgo, Mexico. On whole serrano and jalapeño stored at 25 ± 2 °C or 3 ± 2 °C, no growth was observed for EPEC, ETEC, EIEC and non-O157-STEC rifampicin resistant strains. After twelve days at 25 ± 2 °C, on serrano peppers all diarrheagenic E. coli pathotypes (DEP) strains had decreased by a total of approximately 3.7 log, whereas on jalapeño peppers the strains had decreased by approximately 2.8 log, and at 3 ± 2 °C they decreased to approximately 2.5 and 2.2 log respectively, on serrano and jalapeño. All E. coli pathotypes grew onto sliced chili peppers and in blended sauce: after 24 h at 25 ± 2 °C, all pathotypes had grown to approximately 3 and 4 log CFU on pepper slices and sauce, respectively. At 3 ± 2 °C the bacterial growth was inhibited.

Behavior of non-O157 Shiga toxin-producing Escherichia coli, enteroinvasive E. coli, enteropathogenic E. coli, and enterotoxigenic E. coli strains on alfalfa sprouts

Data about the behavior of non-O157 Shiga toxin-producing Escherichia coli (non-O157 STEC), enteroinvasive E. coli (EIEC), enterotoxigenic E. coli (ETEC), and enteropathogenic E. coli (EPEC) on seeds and alfalfa sprouts are not available. The behavior of STEC, EIEC, ETEC, and EPEC was determined during germination and sprouting of alfalfa seeds at 20 ± 2°C and 30 ± 2°C and on alfalfa sprouts at 3 ± 2°C. When alfalfa seeds were inoculated with STEC, EIEC, ETEC, or EPEC strains, all these diarrheagenic E. coli pathotypes (DEPs) grew during germination and sprouting of seeds, reaching counts of approximately 5 and 6 log CFU/g after 1 day at 20 ± 2°C and 30 ± 2°C, respectively. However, when the sprouts were inoculated after 1 day of seed germination and stored at 20 ± 2°C or 30 ± 2°C, no growth was observed for any DEP during sprouting at 20 ± 2°C or 30 ± 2°C for 9 days. Refrigeration reduced significantly (P < 0.0.5) the number of viable DEPs on sprouts after 20 days in storage; nevertheless, these decreases have no practical significance for the safety of the sprouts.

Prevalence and antibiotic resistance profiles of diarrheagenic Escherichia coli strains isolated from food items in northwestern Mexico

Diarrheogenic Escherichia coli (DEC) strains are an important cause of intestinal syndromes in the developing world mainly affecting children. DEC strains often infect tourists from developed countries traveling to Mexico, causing so-called "traveler diarrhea". DEC strains are typically transmitted by contaminated food and water; however, the prevalence of these strains in food items that are produced, consumed and sometimes exported in northwestern Mexico has not been evaluated. In this study, we conducted a large microbiological survey of DEC strains in 5162 food items and beverages consumed throughout Sinaloa state during 2008 and 2009. We developed a panel of eight sequential PCR reactions that detected the presence of all DEC categories, including typical or atypical variants. Thermotolerant coliforms (also known as fecal coliforms) and E. coli were detected by conventional bacteriology in 13.4% (692/5162) and 7.92% (409/5162) of food items, respectively. Among 409 E. coli isolates, 13.6% (56/409) belonged to DEC strains. Dairy products (2.8%) were the most contaminated with DEC, while DEC strains were not detected in beverages and ice samples. The pathogenic type that was most commonly isolated was EPEC (78.5%), followed by EAEC (10.7%), STEC (8.9%) and ETEC (1.7%). EHEC, DAEC and EIEC strains were not detected. Approximately 80% of EPEC and EAEC strains were classified as atypical variants; they did not adhere to a culture of HEp-2 cell. Of the isolated DEC strains, 66% showed resistance to at least one commonly prescribed antibiotic. In conclusion, the presence of DEC strains in food items and beverages available in northwestern Mexico is low and may not represent a threat for the general population or those traveling to tourist areas.

Effect of frequency and waveform on inactivation of Escherichia coli O157:H7 and Salmonella enterica Serovar Typhimurium in salsa by ohmic heating

The effect of frequency of alternating current during ohmic heating on electrode corrosion, heating rate, inactivation of food-borne pathogens, and quality of salsa was investigated. The impact of waveform on heating rate was also investigated. Salsa was treated with various frequencies (60 Hz to 20 kHz) and waveforms (sine, square, and sawtooth) at a constant electric field strength of 12.5 V/cm. Electrode corrosion did not occur when the frequency exceeded 1 kHz. The heating rate of the sample was dependent on frequency up to 500 Hz, but there was no significant difference (P > 0.05) in the heating rate when the frequency was increased above 1 kHz. The electrical conductivity of the sample increased with a rise in the frequency. At a frequency of 60 Hz, the square wave produced a lower heating rate than that of sine and sawtooth waves. The heating rate between waveforms was not significantly (P > 0.05) different when the frequency was >500 Hz. As the frequency increased, the treatment time required to reduce Escherichia coli O157:H7 and Salmonella enterica serovar Typhimurium to below the detection limit (1 log CFU/g) decreased without affecting product quality. These results suggest that ohmic heating can be effectively used to pasteurize salsa and that the effect of inactivation is dependent on frequency and electrical conductivity rather than waveform.

Presence of faecal coliforms, Escherichia coli and diarrheagenic E. coli pathotypes in ready-to-eat salads, from an area where crops are irrigated with untreated sewage water

Consumption of ready-to-eat (RTE) salads has increased worldwide. Consequently, the number of outbreaks caused by food-borne pathogens, including diarrheagenic E. coli pathotypes (DEPs), associated with the consumption of RTE-salads has increased. DEPs include enterotoxigenic (ETEC), typical and atypical enteropathogenic (tEPEC, aEPEC), enteroinvasive (EIEC), enteroaggregative (EAEC), diffuse adherent (DAEC) and Shiga toxin-producing (STEC) E. coli. In less-developed areas of the world, fresh crops continue to be irrigated with untreated sewage water. The aims of this study were to evaluate the microbiological quality and prevalence of DEPs in RTE-salads of raw vegetables, purchased from restaurants at Pachuca-City, Hidalgo, Mexico, where most locally consumed vegetables are irrigated with untreated sewage water. A total of 130 salads were purchased from restaurants of three categories: A) national chain restaurants and B) local restaurants, both with the H distinctive (a recognition that the Secretary of Tourism grants to restaurants that manage supplies with high levels of hygiene); and C) local small inexpensive restaurants without H distinctive. A total of 6 restaurants were included, 2 per category (A(1-2), B(1-2), C(1-2)). Each sample was tested for the presence of faecal coliforms (FC) and E. coli by standard procedures. E. coli strains were further characterized for the presence of DEPs loci by two multiplex polymerase chain reactions. Among the 130 salad samples 99% (129) were contaminated with FC; 85% (110/129) harboured E. coli and 7% (8/110) DEPs. The amount of positive salad samples for FC and E. coli was similar between restaurants and categories. The FC mean (571 FC/g) of all samples was significantly higher (p<0.001) than the E. coli mean (63 E. coli/g). A weak correlation of 7.7% (r(2)=0.077, p=0.003) between median FC and E. coli MPN (most probable number) per sample was found. Of the 8 salad samples contaminated with DEPs, 2 were spinach salads from restaurant A(2) and 3 were (Mixed salad) samples from each C restaurant. Three samples harboured non-O157 STEC strains, 2 EIEC, 1 ETEC and 2 samples had non-O157 STEC and EIEC strains, simultaneously. A significant difference (p=0.008) between the prevalence of E. coli vs. DEPs was observed. Independently of the restaurants' overall hygienic status, most RTE-salads had a poor microbiological quality and some harboured DEPs that have been associated with illness in Mexico. Health authorities should focus on implementing DEPs screening in raw vegetables and enforcing the legislation that forbids irrigation with untreated sewage water of both root and leafy vegetables.

Frequency and behavior of Salmonella and Escherichia coli on whole and sliced jalapeño and serrano peppers

The frequencies of coliform bacteria (CB), thermotolerant coliforms (TC), Escherichia coli, and Salmonella were determined for jalapeño and serrano peppers. In addition, the behavior of four serotypes of Salmonella and three E. coli strains on whole and sliced jalapeño and serrano peppers as well as in blended sauce at 25 ± 2°C and 3 to 5°C was investigated. Chili peppers were collected from markets in the city of Pachuca, Hidalgo, Mexico. CB, TC, E. coli, and Salmonella were detected on serrano peppers in 100, 90, 50, and 10 % of the samples, and on jalapeño peppers in 100, 86, 32, and 12 % of the samples. Concentrations of CB ranged from 3.8 to 7.9 log CFU per serrano sample and from 5.3 to 8.2 log CFU per jalapeño sample, whereas concentrations of TC and E. coli were between < 3 and 1,100 most probable number per serrano and jalapeño samples. On whole serrano and jalapeño peppers stored at 25 ± 2°C or 3 to 5°C, no growth was observed for rifampin-resistant strains of Salmonella and E. coli. After 6 days at 25 ± 2°C, the tested Salmonella serotypes and E. coli strains had decreased from an initial inoculum level of 5 log CFU to 1 and 2.5 log on serrano and jalapeño peppers, respectively, and at 3 to 5°C they decreased to approximately 1.8 and 1.2 log, respectively, on serrano and jalapeño. Both the Salmonella serotypes and E. coli grew on sliced chili peppers and in blended sauce; after 24 h at 25 ± 2°C, both bacteria types had grown to approximately 4 and 5 log CFU on pepper slices and in sauce, respectively. At 3 to 5°C the bacterial growth was inhibited.

Survival and growth of Salmonella in salsa and related ingredients

A large outbreak of Salmonella Saintpaul associated with raw jalapeño peppers, serrano peppers, and possibly tomatoes was reported in the United States in 2008. During the outbreak, two clusters of illness investigated among restaurant patrons were significantly associated with eating salsa. Experiments were performed to determine the survival and growth characteristics of Salmonella in salsa and related major ingredients, i.e., tomatoes, jalapeño peppers, and cilantro. Intact and chopped vegetables and different formulations of salsas were inoculated with a five-strain mixture of Salmonella and then stored at 4, 12, and 21 degrees C for up to 7 days. Salmonella populations were monitored during storage. Salmonella did not grow, but survived on intact tomatoes and jalapeño peppers, whereas significant growth at 12 and 21 degrees C was observed on intact cilantro. In general, growth of Salmonella occurred in all chopped vegetables when stored at 12 and 21 degrees C, with chopped jalapeño peppers being the most supportive of Salmonella growth. Regardless of differences in salsa formulation, no growth of Salmonella (initial inoculation ca. 3 log CFU/g) was observed in salsa held at 4 degrees C; however, rapid or gradual decreases in Salmonella populations were only observed in formulations that contained both fresh garlic and lime juice. Salmonella grew at 12 and 21 degrees C in salsas, except for those formulations that contained both fresh garlic and lime juice, in which salmonellae were rapidly or gradually inactivated, depending on salsa formulation. These results highlight the importance of preharvest pathogen contamination control of fresh produce and proper formulation and storage of salsa.

The role of rifaximin in the treatment and chemoprophylaxis of travelers' diarrhea

Travelers’ diarrhea is a common illness among international travelers from developed to developing countries. Travelers’ diarrhea is caused by ingestion of contaminated food and water. Bacteria are the primary cause of travelers’ diarrhea. In most surveys, the most common diarrheal pathogen identified is enterotoxigenic Escherichia coli. There are several antimicrobial agents available for the treatment of travelers’ diarrhea including rifaximin which is approved in the United States for the treatment of travelers’ diarrhea due to noninvasive E. coli strains. In this review, we will review the most recent advances of rifaximin for the treatment and prevention of travelers’ diarrhea, with regard to its pharmacokinetics, in vitro susceptibility profile, and efficacy and safety data from clinical trials.

Diagnosis and treatment of acute or persistent diarrhea

Studies of microbial pathogens and the toxins they produce are important for determining the mechanisms by which they cause disease and spread throughout a population. Some bacteria produce secretory enterotoxins (such as cholera toxin or the heat-labile or stable enterotoxins produced by Escherichia coli) that invade cells directly. Others invade cells or produce cytotoxins (such as those produced by Shigella, enteroinvasive E coli, or Clostridium difficile) that damage cells or trigger host responses that cause small or large bowel diseases (such as enteroaggregative or enteropathogenic E coli or Salmonella). Viruses (such as noroviruses and rotaviruses) and protozoa (such as Cryptosporidium, Giardia, or Entamoeba histolytica) disrupt cell functions and cause short- or long-term disease. Much epidemiologic data about these pathogens have been collected from community- and hospital-acquired settings, as well as from patients with traveler's or persistent diarrhea. These studies have led to practical approaches for prevention, diagnosis, and treatment.

Expert review of the evidence base for prevention of travelers' diarrhea

The most frequent illness among persons traveling from developed to developing countries is travelers' diarrhea. Travelers to high-risk regions traditionally have been educated to exercise care in food and beverage selection. Innovative research is needed to identify ways to motivate people to exercise this care and to determine its value. Chemoprophylaxis can be recommended for certain groups while monitoring for safety, drug resistance, and efficacy against all forms of bacterial diarrhea. Research to evaluate the value of immunoprophylaxis is recommended. In the following document, the authors used an evidence base when available to determine strength and quality of evidence and when data were lacking, the panel experts provided consensus opinion.

LargeSalmonellaEnteritidis outbreak with prolonged transmission attributed to an infected food handler, Texas, 2002

In March 2002, an outbreak ofSalmonellaEnteritidis (SE) infections occurred at a convention centre in Dallas, Texas and continued for 6 weeks. We conducted epidemiological studies, obtained clinical and environmental cultures, and interviewed employees to identify risk factors for infection. From 17 March–25 April 2002, the implicated hotel kitchen catered 41 multi-day conferences attended by 9790 persons. We received 617 illness reports from residents of 46 states. Sauces or items served with sauces were implicated in three cohort studies. SE phage-type 8 was identified as the agent. Eleven food service employees, including one who prepared sauces and salsa, had stool cultures that yielded SE. Although the original source was not determined, prolonged transmission resulted in the largest food handler-associated outbreak reported to date, affecting persons from 46 US states. Transmission ended with implementation of policies to screen food handlers and exclude those whose stool cultures yielded salmonellas.

Coliform contamination of vegetables obtained from popular restaurants in Guadalajara, Mexico, and Houston, Texas

Food is the primary vehicle of transmission for traveler's diarrhea. We evaluated coliform contamination of vegetables from popular restaurants in Guadalajara, Mexico, and Houston, Texas. Contamination of vegetables in Guadalajara restaurants was widespread. Prevention of traveler's diarrhea by avoidance of "high-risk" foods may be unsuccessful, because contamination of foods may occur regardless of how they are prepared.

Systematic review: prevention of travellers' diarrhoea

BACKGROUND

Renewed interest in the use of antibiotics to prevent travellers' diarrhoea has occurred with the availability of non-absorbed (<0.4%) rifaximin, and with evidence that a subgroup of travellers with diarrhoea have progression of their illnesses to postinfectious irritable bowel syndrome.

AIM

To summarize recently published information and make recommendations on travellers' diarrhoea prevention.

METHODS

PubMed was reviewed on 2 January 2008 for 255 articles on the topic of 'travellers diarrhoea' published beginning with 2000 along with the author's extensive file on prevention of travellers' diarrhoea.

RESULTS

Exercising care in food and beverage selection, while of unproven value, is recommended during travel to high-risk areas of Latin America, Southern Asia or Africa. An algorithm is presented to identify future travellers, for which chemoprophylaxis is appropriate. The preferred drug for prevention of travellers' diarrhoea is rifaximin, with bismuth subsalicylate or a fluoroquinolone also being effective. Vaccines against the principal cause of travellers' diarrhoea, enterotoxigenic Escherichia coli, are being developed.

CONCLUSIONS

Research is needed to determine the relative effectiveness of exercising care on food and beverage selection and chemoprophylaxis in preventing travellers' diarrhoea and postinfectious irritable bowel syndrome during high-risk travel. Enterotoxigenic E. coli vaccines appear to be a promising addition to travel medicine.

Enterotoxigenic Escherichia coli (ETEC): a recurring decimal in infants' and travelers' diarrhea

Enterotoxigenic Escherichia coli (ETEC) is an important cause of diarrhea in infants and in travelers from developed to underdeveloped countries, especially in regions of poor sanitation. The ETEC are acquired by the ingestion of contaminated food and water, and adults living in endemic areas develop immunity. The disease condition manifests as a minor discomfort to a severe cholera-like syndrome and requires colonization by the microorganism and the elaboration of one or more enterotoxins. The ETEC attach to the epithelial cells of the gastrointestinal tract and release substances that affect the normal functioning of the tract, thereby resulting in diarrhea, and subsequently millions of deaths everyday, particularly in children. The prevention of the spread of this strain of diarrheagenic E. coli depends on ensuring appropriate sanitary measures; hand-washing and proper preparation of food; chlorination of water supplies; and appropriate sewage treatment and disposal. Parenteral or oral fluid and electrolyte replacement is used to prevent dehydration, and broad-spectrum antibiotics are used in chronic or life-threatening cases, but in most cases, should be avoided because of severe side effects.

Transcutaneous immunization with the heat-labile toxin (LT) of enterotoxigenic Escherichia coli (ETEC): Protective efficacy in a double-blind, placebo-controlled challenge study

BACKGROUND

An enterotoxigenic Escherichia coli (ETEC) vaccine could reduce diarrhea among children in developing countries and travelers to these countries. The heat-labile toxin (LT) of ETEC is immunogenic but too toxic for oral or nasal vaccines.

METHODS

In a double-blind, placebo-controlled trial, 59 adults were randomized to receive 50 microg of LT or placebo in a patch applied to alternating arms on days 0, 21, and 42. On day 56, 27 vaccinees and 20 controls were challenged orally with 6x10(8) cfu of LT+/ST+ ETEC.

RESULTS

100 and 97% of vaccinees had 4-fold increases in anti-LT IgG and IgA, and 100 and 90% developed IgG- and IgA-antibody-secreting cell responses. The study did not meet the primary endpoint: 82% of vaccinees and 75% of controls had moderate to severe ETEC illness. However, vaccinees with ETEC illness had lower numbers (6.8 versus 9.7, p=0.04) and weights of loose stools (840 g versus 1147 g, p<0.05), a decreased need for intravenous fluids (14% versus 40%, p=0.03) and a delayed onset of diarrhea (30 h versus 22 h, p=0.01).

CONCLUSIONS

Transcutaneous LT vaccination induced anti-toxin immune responses that did not prevent but mitigated illness following a high-dose challenge with a virulent LT+/ST+ ETEC strain.

Gastrointestinal infections in the traveling athlete

Because athletes travel to competitions all over the world, sports medicine providers need to be able to diagnose and treat gastrointestinal infections. Traveler's diarrhea (TD) is by far the most common gastrointestinal illness. TD is a self-limited condition caused by bacteria, viruses, or parasites, and it can easily be treated. Nevertheless, there are preventative measures that should be taken to limit the exposure to TD in the first place.

Error-prone DNA repair system in enteroaggregative Escherichia coli identified by subtractive hybridization

Enteroaggregative Escherichia coli (EAEC) are etiologic agents of diarrhea. The EAEC category is heterogeneous, but most in-depth experimentation has focused on prototypical strain, 042. We hypothesized that 60A, another EAEC strain, might posses virulence or fitness genes that 042 does not have. Through subtractive hybridization we identified 60A-specific sequences, including loci present in other E. coli and phage DNA. One locus thus identified was impB, a LexA repressed error-prone DNA repair gene that has been identified in plasmids from other enteric organisms and which we detected in 21 of 34 EAEC strains. An isogenic 60A impB mutant showed decreased survival and mutagenesis after exposure to UV, as well as bile salt exposure, compared to the wild-type strain, and these phenotypes could be complemented in trans. The EAEC strain 60A imp operon differs structurally from previously described homologs. A cryptic gene, impC, present in other imp operons, is absent from 60A. In addition, transcription of impAB in strain 60A occurs from a promoter that is dissimilar to the previously described impC promoter but is still triggered by UV-mediated damage. In strain 60A the impAB and the aggregative adherence fimbriae I (AAF/I)-encoding genes are on the same large plasmid, and the 60A version of the operon is predominantly seen in AAF/I-positive EAEC. Supplementary imp SOS-inducible error-prone repair systems are common among EAEC even though they are absent in prototypical strain 042.

A novel single-nucleotide polymorphism in the lactoferrin gene is associated with susceptibility to diarrhea in North American travelers to Mexico

BACKGROUND

Diarrhea affects 40%-60% of travelers from industrialized nations who visit developing countries and is due to bacterial, viral, and parasitic agents. Lactoferrin is bactericidal to enteric pathogens, modulates the intestinal immune response, and is excreted in stool in response to infection with intestinal organisms. We investigated the impact that selected single-nucleotide polymorphisms (SNPs) in the human lactoferrin gene have on susceptibility to traveler's diarrhea.

METHODS

Adults who had recently arrived in Mexico were studied prospectively for the occurrence and causal agent(s) of traveler's diarrhea, and genotyping was performed for 9 distinct lactoferrin SNPs.

RESULTS

Of the 9 SNPs studied, only 1 SNP (located in exon 15) was associated with traveler's diarrhea (P=.004). When compared with healthy travelers, and after adjustment for known risk factors for traveler's diarrhea (such as age and duration and season of travel), subjects with the T/T genotype in amino acid position 632 were more likely to develop traveler's diarrhea (67% vs. 33%; relative risk [RR], 1.4; 95% CI, 1.2-1.7; P<.001), to have diarrhea with a pathogen identified (RR, 1.3; 95% CI, 1.1-1.6; P=.03), and to have a marker of intestinal inflammation in stool specimens (blood, mucus, or white blood cells; 52% vs. 38%; P=.036). The association was also significant when norovirus was not identified in stool samples (RR, 1.34; 95% CI, 1.06-1.34; P=.01).

CONCLUSIONS

The T/T genotype in position codon 632 of the lactoferrin gene is associated with susceptibility to diarrhea in North Americans traveling to Mexico.

Looking for evidence that personal hygiene precautions prevent traveler's diarrhea

In the 50 years during which traveler's diarrhea has been studied, it has always been assumed that personal hygiene precautions can prevent or reduce the likelihood of developing traveler's diarrhea. However, 7 of 8 studies that specifically addressed this issue showed no correlation between the types of food selected and the risk of acquiring traveler's diarrhea. The eighth study showed a correlation between a few dietary mistakes and a decreased risk of acquiring traveler's diarrhea. A further increase in the number of dietary mistakes, however, did not continue to increase the risk of acquiring traveler's diarrhea. Personal hygiene precautions, when performed under the direct supervision of an expatriate operating his or her own kitchen, can prevent traveler's diarrhea, but poor restaurant hygiene in most developing countries continues to create an insurmountable risk of acquiring traveler's diarrhea.

Epidemiology of traveler's diarrhea

Among travelers from developed countries who visit developing countries, >60% may experience traveler's diarrhea, accounting for 40,000 travelers daily or >15 million travelers annually. Traveler's diarrhea is often accompanied by other symptoms, most often abdominal cramps. Although the spontaneous cure occurs after a mean of 4 days, a few patients have symptoms for weeks, and it is increasingly noted that some patients may later develop irritable bowel syndrome. Traveler's diarrhea is life threatening only exceptionally, but it frequently it leads to incapacitation. Both host factors (e.g., age, behavior, nationality, and genetic factors) and environmental factors (primarily the selected destination and hotel) play an important role in risk for traveler's diarrhea.

Analysis of strategies to successfully vaccinate infants in developing countries against enterotoxigenic E. coli (ETEC) disease

Enterotoxigenic Escherichia coli (ETEC) is the most common bacterial cause of diarrhoea in the world, annually affecting up to 400,000,000 children under 5 years of age living in developing countries (DCs). Although ETEC possesses numerous antigens, the relatively conserved colonization factor (CF) antigens and the heat labile enterotoxin (LT) have been associated with protection and most vaccine candidates have exploited these antigens. A safe and effective vaccine against ETEC is a feasible goal as supported by the acquisition of protective immunity. The success of an ETEC vaccine targeting infants and children in DCs will depend on a combination of maximally antigenic vaccine preparations and regimens for their delivery which will produce optimal immune responses to these antigens. Vaccine candidates having a high priority for accelerated development and clinical testing for eventual use in infants would include inactivated ETEC or Shigella hybrids expressing ETEC antigens as well as attenuated ETEC strains which express the major CF antigens and LT toxin B-subunit, as well as attenuated Shigella, Vibrio cholerae and Salmonella typhi hybrids engineered to deliver antigens of ETEC. Candidates for an ETEC vaccine would have to meet the minimal requirement of providing at least 50% protection against severe disease in DCs during the first 2 years of life. The critical roadblock to achieving this goal has not been the science as much as the lack of a sufficiently funded and focused effort to bring it to realization. However, a Product Development Partnership to overcome this hurdle could accelerate the time lines towards when control of ETEC disease in DCs is substantially closer.

A review of an emerging enteric pathogen: enteroaggregative Escherichia coli

Enteroaggregative Escherichia coli (EAEC) is an increasingly recognized enteric pathogen. It is a cause of both acute and persistent diarrhoea among children, adults and HIV-infected persons, in both developing and developed countries. In challenge studies, EAEC has caused diarrhoeal illness with the ingestion of 1010 c.f.u. Outbreaks of diarrhoeal illness due to EAEC have been reported, and linked to the ingestion of contaminated food. Diarrhoeal illness due to EAEC is the result of a complex pathogen–host interaction. Some infections due to EAEC result in diarrhoeal illness and elicit an inflammatory response, whereas other infections do not result in a symptomatic infection. Many putative virulence genes and EAEC strains that produce biofilm have been identified; however, the clinical significance of these genes and of biofilm production has yet to be defined. A −251 AA single nucleotide polymorphism (SNP) in the interleukin (IL)-8 promoter region is reported to increase host susceptibility to EAEC diarrhoea. Ciprofloxacin and rifaximin continue to be an effective treatment in persons infected with EAEC. This review is intended to provide an updated review for healthcare workers on EAEC, an emerging enteric pathogen.

Enteroaggregative Escherichia coli from humans and animals differ in major phenotypical traits and virulence genes

Enteroaggregative Escherichia coli (EAEC) is characterized by the expression of the aggregative adherence pattern to cultured epithelial cells. In this study, we determined the phenotypic and genotypic relationships among 86 EAEC strains of human and animal (calves, piglets and horses) feces. Serotypes and the presence of EAEC virulence markers were determined, and these results were associated with ribotyping. Strains harboring aggR (typical EAEC) of human origin were found carrying several of the searched markers, while atypical EAEC harbored none or a few markers. The strains of animal origin were classified as atypical EAEC (strains lacking aggR) and harbored only irp2 or shf. Strains from humans and animals belonged to several different serotypes, although none of them prevailed. Sixteen ribotypes were determined, and there was no association with virulence genes profiles or serotypes. Relationship was not found among the strains of this study, and the assessed animals may not represent a reservoir of human pathogenic typical EAEC.

Current and future developments in travelers' diarrhea therapy

Diarrhea continues to be the leading health problem among international travelers to developing tropical and semi-tropical regions. Despite more than 50 years of research providing information about the etiology and pathogenesis of the disease, the rate of illness and consequences remain unchanged. An estimated 40% of travelers to developing nations will become ill with diarrhea. Although travelers' diarrhea is considered a self-limited disease, novel and effective approaches to disease prevention and treatment have been realized in recent years. Also, recent evidence has identified a potential for long-term complications of the illness, including postinfectious irritable bowel syndrome. With the advent of poorly absorbed (<0.4%) rifaximin, a treatment option for the common watery diarrhea syndrome equivalent to previously used absorbed antibacterial drugs has emerged. Rifaximin with an excellent safety profile and limited potential to induce coliform resistance, prevents most of the diarrhea that would otherwise occur. With further studies in different settings, new consideration should be given to the routine use of chemoprophylaxis for travelers to high-risk countries. Antibacterial drugs will continue to be the optimal treatment for travelers' diarrhea subjects for the most part caused by bacterial enteropathogens and shorten the duration of diarrhea by 1-2 days compared with no active drug treatment.

Prevention and self-treatment of traveler's diarrhea

Of the millions who travel from the industrialized world to developing countries every year, between 20% and 50% will develop at least one episode of diarrhea, making it the most common medical ailment afflicting travelers. Although usually a mild illness, traveler's diarrhea can result in significant morbidity and hardship overseas. Precautions can be taken to minimize the risk of developing traveler's diarrhea, either through avoidance of potentially contaminated food or drink or through various prophylactic measures, including both nonpharmacological and antimicrobial strategies. If diarrhea does develop despite the precautions taken, effective treatment-usually a combination of an antibiotic and an antimotility agent-can be brought by the traveler and initiated as soon as symptoms develop. In the future, vaccines-several of which are in the advanced stages of clinical testing-may be added to the list of prophylactic measures.

New insights and directions in travelers' diarrhea

Since first studied more than 5 decades ago the risk of travelers'diarrhea for persons going from industrialized regions to developing countries has remained high. Most cases of illness are caused by bacterial agents. Travelers' diarrhea is associated with temporary disability and it may progress to chronic intestinal illness and postinfectious irritable bowel syndrome. Exercising care about food and beverage intake, the use of rifaximin prophylaxis for selective patients, and self-treatment of all resultant illness will continue to be the way in which the disease is prevented or managed best by travelers. Future approaches will be aimed at making host regions safer and providing more effective methods of treatment and prevention of enteric disease during short-term international travel.

Travelers’ diarrhea: Modern concepts and new developments

Travelers' diarrhea occurs when persons move from industrialized regions to developing countries with reduced hygiene. Bacterial enteropathogens from ingested food are the primary causes. Although it is possible to reduce the occurrence of illness by careful selection of food and beverages, travelers do not seem willing to restrict their diets. Diarrhea is associated with a disability of 24 hours per episode, interfering with travel plans and, of even greater concern, post-diarrhea irritable bowel syndrome (IBS) occurs in up to 10% of patients. The use of rifaximin, a poorly absorbed drug, is likely to become common as an attempt to prevent diarrhea and post-infectious IBS. All travelers to high-risk areas should take with them an effective antibacterial drug (rifaximin, fluoroquinolones, or azithromycin) for self-treatment of diarrhea occurring during travel. Additional work is needed to improve the hygienic conditions found in the developing world into which susceptible persons travel.

Multiplex real-time PCR detection of heat-labile and heat-stable toxin genes in enterotoxigenic Escherichia coli

A multiplex real-time PCR method was developed for detection of heat-labile and heat-stable toxin genes in enterotoxigenic Escherichia coli. Approximately 10 CFU per reaction mixture could be detected in rinsates from produce samples. Several foods representative of varieties previously shown to have caused enterotoxigenic E. coli outbreaks were spiked and enriched for 4 or 6 h. Both heat-labile and heat-stable toxin genes could be detected in the foods tested, with the exception of hot sauce, with threshold cycle values ranging from 25.2 to 41.1. A procedure using membrane filtration which would allow enumeration of the enterotoxigenic E. coli population in a food sample in less than 28 h by real-time PCR analysis of colonies picked from media highly selective for E. coli was also developed.

Current concepts in travelers' diarrhea: epidemiology, antimicrobial resistance and treatment

PURPOSE OF REVIEW

The aim of this article is to review recent advances in travelers' diarrhea, which remains one of the most common health problems afflicting individuals from developed countries visiting less affluent regions of the world.

RECENT FINDINGS

A large epidemiologic study done at the point of departure provided insights into regional risk factors for travelers' diarrhea and demonstrated that visitors rarely exercised dietary precautions aimed at disease prevention. A preventive program implemented with the close interaction between public health agencies, hotel industry and academia can result in effective reduction of cases. A polymorphism in the IL-8 gene promoter is associated with susceptibility to diarrhea due to enteroaggregative Escherichia coli. New diagnostic tools assist in better understanding the role of norovirus and emerging bacterial enteric pathogens such as enteroaggregative E. coli. Rifaximin, a non-absorbable antibiotic, is a safe and effective alternative for the prevention and treatment of travelers' diarrhea due to non-invasive organisms.

SUMMARY

Traditional public health and new antimicrobial agents can decrease the risk of travel related diarrhea.

Antibacterial Chemoprophylaxis in the Prevention of Traveler's Diarrhea: Evaluation of Poorly Absorbed Oral Rifaximin

The use of antibacterial drugs was first shown to effectively reduce the occurrence of traveler's diarrhea nearly 50 years ago. The approach was not encouraged for general use by a Consensus Development Conference in 1985 because of concerns about adverse effects of the drugs and the possible development of resistance against systemically absorbed drugs. When therapy with poorly absorbed rifaximin was shown to be as effective as therapy with systemically absorbed drugs in shortening the duration of traveler's diarrhea, without the development of resistant coliform flora, the use of rifaximin for the prevention of traveler's diarrhea was studied. In the present study, rifaximin provided 72% protection against the development of diarrhea and 77% protection against active or treated diarrhea during 2 weeks of drug administration to United States students in Mexico. Rifaximin offers a potentially useful approach for preventing traveler's diarrhea. Potential areas of future study include use of the drug to prevent diarrhea due to mucosally invasive bacteria, including ciprofloxacin-resistant Campylobacter species, and to reduce the occurrence of postinfectious irritable bowel syndrome.

Enterotoxigenic Escherichia coli in developing countries: epidemiology, microbiology, clinical features, treatment, and prevention

ETEC is an underrecognized but extremely important cause of diarrhea in the developing world where there is inadequate clean water and poor sanitation. It is the most frequent bacterial cause of diarrhea in children and adults living in these areas and also the most common cause of traveler's diarrhea. ETEC diarrhea is most frequently seen in children, suggesting that a protective immune response occurs with age. The pathogenesis of ETEC-induced diarrhea is similar to that of cholera and includes the production of enterotoxins and colonization factors. The clinical symptoms of ETEC infection can range from mild diarrhea to a severe cholera-like syndrome. The effective treatment of ETEC diarrhea by rehydration is similar to treatment for cholera, but antibiotics are not used routinely for treatment except in traveler's diarrhea. The frequency and characterization of ETEC on a worldwide scale are inadequate because of the difficulty in recognizing the organisms; no simple diagnostic tests are presently available. Protection strategies, as for other enteric infections, include improvements in hygiene and development of effective vaccines. Increases in antimicrobial resistance will dictate the drugs used for the treatment of traveler's diarrhea. Efforts need to be made to improve our understanding of the worldwide importance of ETEC.

Enteroaggregative Escherichia coli: An emerging pathogen in children

Enteroaggregative Escherichia coli (EAEC) is an emerging pathogen that causes enteric and food-borne infectious diseases. Children throughout the world appear to be susceptible to EAEC infection. EAEC pathogenesis involves the following three stages: 1) adherence to the intestinal mucosa; 2) increased production and deposition of a mucus biofilm; and 3) mucosal toxicity due to inflammation and cytokine release. The HEp-2 cell adherent assay allows identification of EAECs characteristic aggregative or "stacked brick" adherence pattern. Antimicrobial treatment of children who develop an EAEC infection should be individually based. All children with EAEC diarrhea should receive adequate oral fluid hydration. For children who have persistent diarrhea and severe dehydrating illness despite having received adequate oral rehydration, antimicrobials may be initiated. Azithromycin and rifaximin have been shown to shorten the course of EAEC diarrhea in adults and probably represent the recommended antimicrobials of choice for children with severe or persistent illness. The objective of this review is to increase awareness of this important emerging pathogen and to discuss the epidemiology, pathogenesis, and pathogen and host factors associated with EAEC infection in children.

Enteroaggregative Escherichia coli: an emerging enteric pathogen

Enteroaggregative Escherichia coli (EAEC) represents an emerging pathogen that causes enteric and food-borne infectious diseases. Subgroups in many populations throughout the world are susceptible to EAEC infection. EAEC pathogenesis involves adherence to the intestinal mucosa; increased production and deposition of a mucus biofilm; and mucosal toxicity due to inflammation and cytokine release. Due to the heterogeneity of EAEC strains and differing host immune responses, not all EAEC infections are symptomatic. Recent data suggest that individuals with a homozygous genotype -251 AA single nucleotide polymorphism (SNP), in the IL-8 promoter region, are more susceptible to EAEC diarrhea. The HEp-2 cell adherent assay allows identification of EAEC's characteristic aggregative or "stacked brick" adherence pattern. Antimicrobial treatment of individuals who develop EAEC diarrhea should be individually based. Ciprofloxacin and rifaximin, compared to placebo, have been shown to significantly shorten the course of diarrhea in patients who developed EAEC infection. The objective of this review is to increase awareness of this important emerging pathogen and to discuss the epidemiology, pathogenesis, and host-pathogen factors associated with EAEC infection.