Basics
Description
Any illness resulting from the ingestion of food or drink contaminated with an infectious organism or associated toxin
Epidemiology
Incidence (U.S. Annual Estimates)
- 31 major pathogens caused
- 9.4 million episodes of foodborne illness
- 56,000 hospitalizations
- 1,350 deaths
- Highest incidence in children <5 years
- Hospitalizations and death more common in persons >64 years
- See Appendix, Table 8 regarding epidemiologic aspects by organism.
General Prevention
- Vaccination
- Oral rotavirus vaccine
- Hepatitis A vaccine
- Preventive strategies
- Hand washing (soap and water)
- Proper food handling (adequate cooking and refrigeration)
- Avoidance of unpasteurized dairy products and juices
- Avoidance of raw or undercooked eggs, meat, and shellfish
- Avoidance of honey in children <1 year old
- Avoidance of well water, which may contain nitrates, in preparing infant formulas
Pathophysiology
- Gastroenteritis
- Viral epithelial invasion/replication or ingestion of preformed elaborated toxin
- Noninflammatory diarrhea
- Selective destruction of absorptive cells in mucosa, leaving secretory cells intact
- Toxin elaboration (secretory diarrhea)
- Impairment of brush border enzymes and lactose intolerance (osmotic diarrhea)
- Inflammatory diarrhea/dysentery
- Direct mucosal invasion of intestinal epithelial cells (colon)
- Toxin elaboration
- Inflammatory infiltration destroys villous cells and transporters and leads to exudation of mucus/protein/blood into gut.
- Local/remote invasion (bacteremia, meningitis, dissemination, hepatitis, osteomyelitis)
- Immune-mediated extraintestinal manifestations (hemolytic uremic syndrome, reactive arthritis, Guillain-Barr ©)
Etiology
- Viruses
- Most common cause of foodborne illness
- Caliciviruses (norovirus)
- Rotavirus (infant/child)
- Astrovirus
- Enteric adenovirus
- Hepatitis A
- Bacteria
- Salmonella (typhi, paraptyphi, non-typhoidal)
- Clostridium perfringens
- Campylobacter
- Other bacteria
- Salmonella typhi/Salmonella paratyphi
- Shigella
- Escherichia coli
- Enterohemorrhagic E. coli [EHEC] including Shiga toxin-producing E. coli [STEC]
- Enteropathogenic E. coli [EPEC]
- Enterotoxigenic E. coli [ETEC]
- Enteroinvasive E. coli [EIEC]
- Enteroaggregative E. coli [EAEC]
- Vibrio (cholerae, parahaemolyticus, vulnificus)
- Staphylococcus aureus (preformed toxin)
- Bacillus cereus (preformed and diarrheal toxin)
- Clostridium botulinum (toxin)
- Listeria monocytogenes
- Brucella
- Parasites
- Entamoeba histolytica
- Giardia intestinalis
- Cryptosporidium
- Cyclospora cayetanensis
- Toxoplasma gondii
Diagnosis
Signs and Symptoms
- Gastroenteritis
- Sudden onset vomiting
- Fever and diarrhea may also be present
- Associated with viral etiology, preformed toxin ingestion
- Noninflammatory diarrhea
- Acute watery diarrhea, abdominal pain, without fever/dysentery
- Some may present with fever
- Consider: ETEC, viral or parasitic etiology
- Inflammatory diarrhea:
- Bloody stool, abdominal pain and fever
- Consider: Shigella, Campylobacter, Salmonella, EIEC, EHEC, STEC O157H7, EAEC, Vibrio parahaemolyticus, Yersinia enterocolitica, Entamoeba
- Chronic diarrhea >14 days
- 3 or more unformed stools/day
- Consider: parasitic etiology
- Neurologic manifestations
- Paresthesias, respiratory depression, bronchospasm, cranial nerve palsies
- Consider: Clostridium botulinum toxin, organophosphate, fish toxin poisons, Guillain-Barr © [Campylobacter jejuni]
- Systemic illness
- Fever, weakness, arthritis, jaundice
- Consider: Listeria, Brucella, Trichinella, Toxoplasma, Vibrio vulnificus, Hep A, S. typhi, S. paratyphi
History
- Incubation period
- Duration of illness
- Predominant symptoms
- Population involved in outbreak
- Similarly exposed persons with related symptoms
- Suspected similarly ill contacts
- Type of food ingested and type of exposure (location of exposure, pet contact, travel, occupation, institutional/daycare)
- See Appendix, Table 9 regarding clinical symptoms by organism.
Physical Exam
- Detailed neurologic examination
- Assessment of dehydration status (examination of mucous membranes, skin turgor)
- Assessment of potential liver involvement (hepatomegaly, jaundice, icterus)
- Assessment of disseminated disease (MS exam for septic arthritis and osteomyelitis)
- Careful abdominal examination
Diagnostic Tests & Interpretation
Lab
- Routine bacterial stool culture
- Cultures for Vibrio and Yersinia, EC0157H7, and Campylobacter require additional media or incubation conditions and may require communication with laboratory if suspected.
- Toxin testing, serotyping, and molecular techniques may only be available from large commercial or public health labs.
- Blood/CSF cultures as clinically indicated
- Serology (hepatitis A, Brucella, Toxo)
- Ova/parasite examination
- Direct antigen testing/DFA (Giardia, Cryptosporidium)
- Polymerase chain reaction (PCR) identification of multiple pathogens in stool (viral, bacterial, parasitic) are most sensitive.
- Careful monitoring of patients with hemorrhagic colitis during illness and 3 days after resolution of diarrhea to detect changes of HUS (CBC with smear, BUN/Cr)
Differential Diagnosis
- Systemic viral illness (myalgias/arthralgias) or infection (e.g., pharyngitis)
- Appendicitis, peritonitis, pelvic inflammatory disease
- Irritable bowel syndrome
- Inflammatory bowel disease
- Malignancy
- Medication use
- Clostridium difficile enterocolitis
- Malabsorption syndromes (celiac disease, cystic fibrosis, malnutrition)
- Food intolerance or allergy
- Cow's milk (protein allergy)
- Carbohydrate intolerance (e.g., lactose)
- Dietary manipulations
- Hyperosmolar formulas
- Food additives (dyes, processing materials, coloring)
- Caffeine
- Overfeeding
- Low fat intakes
- Excessive fluids
- Munchausen by proxy
- Ingestion of noninfectious foodborne illness (contaminated seafood, mushroom poisoning, chemical poisoning)
Treatment
Additional Treatment
General Measures
- Gastroenteritis
- Treat dehydration with oral rehydration solution (ORS):
- Standard ORS contains 75-90 mEq of sodium and 74-111 mmol/L of glucose
- Alternative ORS, including rice-based carbohydrate or amylase-based solutions, may be more effective for Vibrio cholerae infections.
- Transition rapidly (after 3-4 hours of ORS tolerance) to regular diet (see below).
- Continue breastfeeding infants if possible.
- Botulism
- Continuous cardiac and respiratory monitoring, may need assisted ventilation
Diet
Balanced, varied diet; providing easily digestible, complex carbohydrates will promote improved stool consistency.
Special Therapy
Botulism: For suspected infant botulism cases, human-derived antitoxin, BabyBIG (Human Botulism Immune Globulin, BIG-IV), may be obtained from the Infant Botulism Treatment and Prevention Program, California Department of Public Health (24-hour line: 510-231-7600).
IV Fluids
If patient is unable to be rehydrated via oral route (because of ileus, circulatory failure, CNS complications) or if >10% dehydration
Complementary & Alternative Therapies
Supplements with specific probiotic strains (e.g., Lactobacillus GG) have been shown to reduce duration of less severe, non-rotaviral diarrhea and hospital stays.
Medication
Use of antibiotics is
- Always indicated
- Shigella
- Brucella
- L. monocytogenes (invasive disease)
- Invasive Salmonella (typhi, paratyphi, non-tyhoidal)
- Typhoid fever (Salmonella typhi, paratyphi)
- Salmonella typhi
- Salmonella paratyphi
- Vibrio spp.
- Cyclospora cayetanensis
- Cryptosporidium (severe or children <12 years old)
- Trichinella
- E. histolytica
- Campylobacter (in severe cases, early treatment limits duration, prevents relapse, and shortens duration of shedding)
- G. intestinalis
- Sometimes indicated
- E. coli (severe ETEC in a traveler in resource limited country)
- Non-typhi Salmonella
- Treatment indicated to reduce risks of bacterial translocation only in a few select populations: patients <3 months old as well as those who are immunocompromised, have a hemoglobinopathy, or have chronic GI condition (IBD)
- Other patients should not be treated, as antibiotics prolong organism shedding in the stool and promote disease spread.
- Y.enterocolitica (sepsis)
- T. gondii (pregnant and immunocompromised patients)
- Cryptosporidium (severe, <12 years of age)
- Contraindicated
- Clostridium botulinum (aminoglycosides potentiate paralytic effects)
- No antimotility agents for children with inflammatory or bloody diarrhea
Ongoing Care
Prognosis
- Most gastroenteritis is mild and self-limited.
- Recovery is complete in 2-5 days in most individuals.
- In the very young, prognosis is more guarded because these patients can become dehydrated quickly.
- After the patient has survived the paralytic phase of botulism, the outlook for complete recovery is excellent.
Reporting Requirements
- Foodborne diseases and conditions generally notifiable at the national level include the following:
- Botulism, brucellosis, STEC O157H7, hemolytic uremic syndrome, listerosis, salmonellosis (other than S. typhi), shigellosis, typhoid fever (S. typhi and S. paratyphi infections), Vibrio, hepatitis A
- Additional reporting requirements may be mandated by state and territorial laws and regulations: Full reporting instructions are available:
- 1-800-CDC-INFO (1-800-232-4636)
- http://www.cdc.gov/foodsafety/fdoss/reporting/how-to-report.html
Additional Reading
- Centers for Disease Control and Prevention. Diagnosis and management of foodborne illnesses. MMWR Recomm Rep. 2004;53(RR-4):1-33. [View Abstract]
- Centers for Disease Control and Prevention. Incidence and trends of infection with pathogens transmitted commonly through food -Foodborne Disease Active Surveillance Network, 10 U.S. sites, 1996-2012. MMWR Morb Mortal Wkly Rep. 2013;62(15):283-287. [View Abstract]
- Davidson G, Barnes G, Bass D, et al. Infectious diarrhea in children: Working group report of the first World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2002;25(Suppl 2):143-150. [View Abstract]
- Greer FR, Shannon M. Infant methemoglobinemia: the role of dietary nitrate in food and water. Pediatrics. 2005;116(3):784-786. [View Abstract]
- NASPGHAN Nutrition Report Committee. Clinical efficacy of probiotics: review of the evidence with a focus on children. J Gastroenterol Hepatol Nutr. 2006;43(4):550-557. [View Abstract]
- Scallan E, Hoekstra RM, Angelo FJ, et al. Foodborne illness acquired in the United States-major pathogens. Emerging Infect Dis. 2011;17(1):7-15. [View Abstract]
Codes
ICD09
- 005.9 Food poisoning, unspecified
- 005.89 Other bacterial food poisoning
- 003.0 Salmonella gastroenteritis
- 008.00 Intestinal infection due to E. coli, unspecified
- 005.2 Food poisoning due to Clostridium perfringens (C. welchii)
- 005.0 Staphylococcal food poisoning
- 005.3 Food poisoning due to other Clostridia
- 005.1 Botulism food poisoning
ICD10
- T62.91XA Toxic effect of unsp noxious sub eaten as food, acc, init
- A05.9 Bacterial foodborne intoxication, unspecified
- A02.0 Salmonella enteritis
- A04.4 Other intestinal Escherichia coli infections
- A05.2 Foodborne Clostridium perfringens intoxication
- A04.5 Campylobacter enteritis
- A05.1 Botulism food poisoning
- A08.4 Viral intestinal infection, unspecified
- A05.0 Foodborne staphylococcal intoxication
- A08.39 Other viral enteritis
- K52.2 Allergic and dietetic gastroenteritis and colitis
SNOMED
- 75258004 food poisoning (disorder)
- 416482004 Food-borne gastroenteritis (disorder)
- 302229004 Salmonella food poisoning
- 240335007 Escherichia coli food poisoning
- 240338009 Viral food poisoning (disorder)
- 111802007 Food poisoning due to Clostridia (disorder)
- 398523009 Foodborne botulism (disorder)
- 415353009 Rotavirus food poisoning (disorder)
FAQ
- Q: What are the most common causes of food poisoning?
- A: Viruses, particularly norovirus, are the leading cause of foodborne illnesses. The most common bacterial infections include Salmonella, Clostridium perfringens, and Campylobacter jejuni.
- Q: How are the signs and symptoms of food poisoning different from those of a viral gastroenteritis?
- A: The signs and symptoms of food poisoning and gastroenteritis are similar in that the patient displays diarrhea, vomiting, and fever. Historically, food poisoning is distinguished by its association with a common food that affects multiple individuals who consumed it.
- Q: Which foods are most likely to be contaminated?
- A: Poorly cooked foods (e.g., eggs, meats, fish, shellfish), unpasteurized milk and juices, inadequately washed fresh produce, home canned goods, soft unpasteurized cheeses. Use of well water, which may be contaminated with nitrates, to prepare infant formula can result in infant methemoglobinemia.