Food Poisoning

http://emedicine.medscape.com/article/175569-overview

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Food Poisoning
Author: Roberto M Gamarra, MD; Chief Editor: Julian Katz, MD more... Updated: Feb 11, 2013

Practice Essentials
Food poisoning is defined as an illness caused by the consumption of food or water contaminated with bacteria and/or their toxins, or with parasites, viruses, or chemicals. The most common pathogens are Norovirus, Salmonella, Clostridium perfringens, Campylobacter, and Staphylococcus aureus .

Essential update: CDC reports most common sources of food-borne illnesses

Using data spanning the decade between 1998 and 2008, CDC investigators reported estimates for annual US food-borne illnesses, hospitalizations, and deaths attributable to each of 17 food categories.[1, 2] Among their findings: (1) leafy green vegetables were the most common cause of food poisoning (22%), primarily due to Norovirus species, followed by E coli O157; (2) poultry was the most common cause of death from food poisoning (19%), with Listeria and Salmonella species being the main infectious organisms; and (3) dairy items were the second most frequent causes of foodborne illnesses (14%) and deaths (10%), with the main factors being contamination by Norovirus from food handlers and improper pasteurization resulting in contamination with Campylobacter species.[1, 2]

Signs and symptoms

The symptoms of food poisoning vary in degree and combination. They may include the following: Abdominal pain: Most severe in inflammatory processes; painful abdominal muscle cramps suggest underlying electrolyte loss Vomiting: Major presenting symptom of S aureus, B cereus, or Norovirus[3] Diarrhea: Usually lasts less than 2 weeks Headache Fever: May be an invasive disease or an infection outside the GI tract Stool changes: Bloody or mucousy if invasion of intestinal or colonic mucosa; profuse rice-watery if cholera or a similar process Reactive arthritis: Seen with Salmonella, Shigella, Campylobacter, and Yersinia infections Bloating: May be due to giardiasis More serious cases of food poisoning can result in life-threatening neurologic, hepatic, and renal syndromes leading to permanent disability or death. See Clinical Presentation for more detail.

Diagnosis
Examination of patients suspected of having food poisoning should focus on assessing the severity of dehydration. General findings may include the following:

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Mild dehydration: A dry mouth, decreased axillary sweat, decreased urine More severe volume depletion: Orthostasis, tachycardia, hypotension Salmonellatyphi infection: Upper abdominal rose spot macules, hepatosplenomegaly Yersinia infection: Erythema nodosum, exudative pharyngitis Vibrio vulnificus or V alginolyticus infection: cellulitis, otitis media Always perform a rectal examination to (1) directly visualize the stool, (2) test occult blood, and (3) palpate the rectal mucosa for any lesions. Testing The following routine laboratory tests may help to assess the patients inflammatory response and the degree of dehydration: CBC with differential Serum electrolyte assessment BUN and creatinine levels Other laboratory studies can be helpful in cases of food poisoning and include the following: Stool Gram staining and Loeffler methylene blue staining for WBCs: To help differentiate invasive disease from noninvasive disease Microscopic examination of the stool: To detect any ova and parasites Bacterial culture for enteric pathogens (eg, Salmonella, Shigella,Campylobacter organisms): Mandatory when a stool sample shows positive results for WBCs or blood or if patients have fever or symptoms persisting for longer than 3-4 days Blood culture in notably febrile patients C difficile assay: To help rule out antibiotic-associated diarrhea in patients receiving antibiotics or in those with a history of recent antibiotic use Imaging studies Obtain flat and upright abdominal radiographs if the patient experiences bloating, severe pain, or obstructive symptoms or if the clinical picture suggests perforation. Procedures Consider performing the following procedures when a stool examination is nondiagnostic, especially in immunocompromised patients: Sigmoidoscopy/colonoscopy with biopsy EGD with duodenal aspirate and biopsy In patients with bloody diarrhea, sigmoidoscopy can be useful in diagnosing inflammatory bowel disease, antibioticassociated diarrhea, shigellosis, and amebic dysentery. See Workup for more detail.

Management
Most food-borne illnesses are mild and improve without any specific treatment. Some patients have severe disease and require hospitalization, aggressive hydration, and antibiotic treatment.[4] Supportive care The main objective in managing patients with food poisoning is adequate rehydration and electrolyte supplementation, which can be achieved with either an oral rehydration solution or intravenous solutions in severely dehydrated individuals or those with intractable vomiting (eg, isotonic sodium chloride solution, lactated Ringer solution). Patients should avoid milk, dairy products, and other lactose-containing foods during episodes of acute diarrhea, as these individuals often develop an acquired disaccharidase deficiency due to washout of the brush-border enzymes. Pharmacotherapy Medications that may be needed to treat patients with food poisoning include the following: Antidiarrheals: Absorbents (eg, attapulgite, aluminum hydroxide); antisecretory agents (eg, bismuth subsalicylate); antiperistaltics (eg, opiate derivatives such as diphenoxylate with atropine, loperamide) Antibiotics (eg, ciprofloxacin, norfloxacin, TMX/SMP, doxycycline, rifaximin): Selection of antibiotic depends on

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clinical setting and guided by microbiology and blood culture sensitivity results Prevention The best ways to prevent food poisoning caused by infectious agents are as follows: Practice strict personal hygiene Cook all foods adequately Avoid cross-contamination of raw and cooked foods Keep all foods at appropriate temperatures (ie, refrigerated items: < 40F; hot items: >140F) See Treatment and Medication for more detail.

Background
Food poisoning is defined as an illness caused by the consumption of food or water contaminated with bacteria and/or their toxins, or with parasites, viruses, or chemicals. The symptoms, varying in degree and combination, include abdominal pain, vomiting, diarrhea, and headache; more serious cases can result in life-threatening neurologic, hepatic, and renal syndromes leading to permanent disability or death. Most of the illnesses are mild and improve without any specific treatment. Some patients have severe disease and require hospitalization, aggressive hydration, and antibiotic treatment.[4] A food-borne disease outbreak is defined by the following 2 criteria: 1. Similar illness, often GI, in a minimum of 2 people 2. Evidence of food as the source

Pathophysiology
The pathogenesis of diarrhea in food poisoning is classified broadly into either noninflammatory or inflammatory types. Noninflammatory diarrhea is caused by the action of enterotoxins on the secretory mechanisms of the mucosa of the small intestine, without invasion. This leads to large volume watery stools in the absence of blood, pus, or severe abdominal pain. Occasionally, profound dehydration may result. The enterotoxins may be either preformed before ingestion or produced in the gut after ingestion. Examples include Vibrio cholerae, enterotoxic Escherichia coli, Clostridium perfringens, Bacillus cereus,[5] Staphylococcus organisms , Giardia lamblia, Cryptosporidium,rotavirus, norovirus (genus Norovirus, previously calledNorwalk virus), and adenovirus. Inflammatory diarrhea is caused by the action of cytotoxin on the mucosa, leading to invasion and destruction. The colon or the distal small bowel commonly is involved. The diarrhea usually is bloody; mucoid and leukocytes are present. Patients are usually febrile and may appear toxic. Dehydration is less likely than with noninflammatory diarrhea because of smaller stool volumes. Fecal leukocytes or a positive stool lactoferrin test indicates an inflammatory process, and sheets of leukocytes indicate colitis. Sometimes, the organisms penetrate the mucosa and proliferate in the local lymphatic tissue, followed by systemic dissemination. Examples include Campylobacter jejuni, Vibrio parahaemolyticus, enterohemorrhagic and enteroinvasive E coli, Yersinia enterocolitica, Clostridium difficile, Entamoeba histolytica, and Salmonella and Shigella species. In some types of food poisoning (eg, staphylococci, B cereus), vomiting is caused by a toxin acting on the central nervous system. The clinical syndrome of botulism results from the inhibition of acetylcholine release in nerve endings by the botulinum. The pathophysiological mechanisms that result in acute GIsymptoms produced by some of the noninfectious causes of food poisoning (naturally occurring substances [eg, mushrooms, toadstools] and heavy metals [eg, arsenic, mercury, lead]) are not well known.

Frequency
United States
Initially, food-borne diseases were estimated to be responsible for 6-8 million illnesses and as many as 9000 deaths each year.[6, 7] However, the change in food supply, the identification of new food-borne diseases, and the availability of new surveillance data have changed the morbidity and mortality figures. The US Centers for Disease Control and Prevention (CDC) estimates 1 in 6 Americans (48 million people) are affected by foodborne illness annually. The

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estimates suggest 128,000 people are hospitalized and 3,000 die.[8] The 31 known pathogens account for an estimated 9.4 million annual cases, 55,961 hospitalizations, and 1,351 deaths. Unspecified agents account for 38.4 million cases, 71,878 hospitalizations, and 1,686 deaths.[9] Overall, food-borne diseases appear to cause more illnesses but fewer deaths than previously estimated.[10] The most common pathogens are as follows:[8] Norovirus 5,461,731 cases Salmonella 1,027,561 C perfringens 965,958 Campylobacter species 845,024 Staphylococcus aureus 241,148 The most common pathogens responsible for hospitalizations are as follows:[8] Salmonella 19,336 hospitalizations Norovirus 14,663 hospitalizations Campylobacter species 8,463 hospitalizations Toxoplasma gondii 4,428 hospitalizations E coli 2,138 hospitalizations The pathogens most commonly associated with death are as follows: Salmonella 378 deaths T gondii 327 deaths Listeria monocytogenes 255 deaths Norovirus 149 deaths Campylobacter species 76 deaths In March 2012, the CDC reported a rise in foodborne disease outbreaks caused by imported food in 2009 and 2011. Nearly 50% of the outbreaks implicated food that was imported from regions not previously associated with outbreaks. Outbreaks reported to CDCs Foodborne Disease Outbreak Surveillance System from 2005-2010 implicated 39 outbreaks and 2,348 illnesses that were linked to imported food from 15 countries. Within this 5-year period, nearly half (17) occurred in 2009 and 2010. Fish (17 outbreaks) were the most common source of implicated imported foodborne disease outbreaks, followed by spices (6 outbreaks including 5 from fresh or dried peppers). Approximately 45% percent of the imported foods causing outbreaks came from Asia.[11] The CDC recognized the following outbreaks and sources in 2012:[8] E coli Spinach and spring mix, raw clover sprouts at a national chain of restaurants Salmonella Peanut butter, ricotta salata cheese, mangoes, cantaloupe, ground beef, live poultry, dry dog food, raw scraped ground tuna product, small turtles, raw clover sprouts

International
Transnational trade; travel; and migration and globalization of food production, manufacturing, and marketing pose greater risk of cross-border transmission of infectious diseases and food-borne illness.[12] A travel history should be obtained because traveler's diarrhea is the leading cause of travel-related illness. Onset occurs 3 days to 2 weeks after arrival. Illness is self-limiting within 5 days. Enterotoxigenic E coli is the most common isolate.

Mortality/Morbidity
Symptoms vary in degree and combination. They may include abdominal pain, vomiting, diarrhea, headache, and prostration. More serious cases can result in life-threatening neurologic, hepatic, and renal syndromes leading to permanent disability or death.

Age
Morbidity and mortality are higher in elderly individuals. The reasons for this increased susceptibility in elderly populations include age-associated decrease in immunity, decreased production of gastric acid and intestinal motility, malnutrition, lack of exercise, habitation in a nursing home, and excessive use of antibiotics. Elderly persons are more likely to die from infection with C perfringens; E coli O157; and Salmonella, Campylobacter, and Staphylococcus organisms. The CDC found that 5 bacterial enteric pathogens (Campylobacter, E coli 0157 , Salmonella, Shigella, and Y enterocolitica) caused 291,162 illnesses annually in children younger than 5 years.[13] This resulted in 102,746 doctor

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visits, 7,830 hospitalizations, and 64 deaths. Rates of illness remain higher in children.

Contributor Information and Disclosures

Author Roberto M Gamarra, MD Consulting Gastroenterologist, Digestive Health Associates, PLC Roberto M Gamarra, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, and Crohns and Colitis Foundation of America Disclosure: Nothing to disclose. Coauthor(s) David Manuel, MD Affiliate Faculty, Department of Medicine, Loyola University Health System; Gastroenterologist, Digestive Health Center David Manuel, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society of Gastrointestinal Endoscopy, and Crohns and Colitis Foundation of America Disclosure: Nothing to disclose. Michael H Piper, MD Clinical Assistant Professor, Department of Internal Medicine, Division of Gastroenterology, Wayne State University School of Medicine; Consulting Staff, Digestive Health Associates, PLC Michael H Piper, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American College of Physicians, and Michigan State Medical Society Disclosure: Nothing to disclose. Senthil Nachimuthu MD, FACP Senthil Nachimuthu is a member of the following medical societies: American College of Physicians Disclosure: Nothing to disclose. Priyankha Balasundaram, MD Director, Kovai Heart Foundation, India; Resident, Department of Surgery, Tulane University School of Medicine Disclosure: Nothing to disclose. Specialty Editor Board Jose A Perez Jr, MD, MBA, MSEd Residency Director, Internal Medicine Residency Program, Vice Chair of Education, Department of Medicine, Methodist Hospital; Associate Professor of Clinical Medicine, Weill Cornell

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Medical College Jose A Perez Jr, MD, MBA, MSEd is a member of the following medical societies: American College of Physician Executives, American College of Physicians, Society of General Internal Medicine, and Society of Hospital Medicine Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Simmy Bank, MD Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine Disclosure: Nothing to disclose. Alex J Mechaber, MD, FACP Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine Disclosure: Nothing to disclose. Chief Editor Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility Disclosure: Nothing to disclose.

References
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11. CDC research shows outbreaks linked to imported foods increasing. Available at http://www.cdc.gov/media /releases/2012/p0314_foodborne.html. Accessed March 14, 2012. 12. Jacobs RA. General problems in infectious diseases: acute infectious diarrhea. In: Tierney LM Jr, McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis and Treatment 2001. 40th ed. New York, NY: McGraw-Hill; 2000:1215-6. 13. Scallan E, Mahon BE, Hoekstra RM, Griffin PM. Estimates of Illnesses, Hospitalizations, and Deaths Caused By Major Bacterial Enteric Pathogens in Young Children in the United States. Pediatr Infect Dis J. Dec 17 2012;[Medline]. 14. Atmar RL, Bernstein DI, Harro CD, et al. Norovirus vaccine against experimental human Norwalk Virus illness. N Engl J Med. Dec 8 2011;365(23):2178-87. [Medline]. 15. Archer DL. Incidence and cost of foodborne diarrheal disease in the United States. J Food Prot. 1985;48:887-94. 16. Butterton JR, Calderwood SB. Acute infectious diarrheal diseases and bacterial food poisoning. In: Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, eds. Harrison's Principles of Internal Medicine. 15th ed. New York, NY: McGraw-Hill; 2001:834-9. 17. Gianella RA. Infectious enteritis and proctocolitis and bacterial food poisoning. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease. Vol 2. 2006:2333-91. 18. Goulet V, Hebert M, Hedberg C, et al. Incidence of listeriosis and related mortality among groups at risk of acquiring listeriosis. Clin Infect Dis. Mar 1 2012;54(5):652-60. [Medline]. 19. Malek M, Barzilay E, Kramer A, et al. Outbreak of norovirus infection among river rafters associated with packaged delicatessen meat, Grand Canyon, 2005. Clin Infect Dis. Jan 1 2009;48(1):31-7. [Medline]. 20. Sherman PM, Wine E. Emerging intestinal infections. Gastroenterology & Hepatology Annual Review. 2006;1:50-54. [Full Text]. 21. Surveillance for foodborne disease outbreaks - United States, 2006. MMWR Morb Mortal Wkly Rep. Jun 12 2009;58(22):609-15. [Medline]. Medscape Reference 2011 WebMD, LLC

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