The practice of travel medicine: guidelines by the Infectious Diseases Society of America.
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Communicable Diseases↗
Biomedical subjects
Charles D Ericsson
Publications and source records attributed to Charles D Ericsson.
Transfusion-transmitted malaria: how satisfactory are current preventative measures?
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Aged↗
Safety and tolerability of the antibacterial rifaximin in the treatment of travellers' diarrhoea.
Although travellers' diarrhoea can sometimes be associated with postinfectious complications, the condition is typically self-limiting. The infectious-diarrhoea guidelines subcommittees of the Infectious Disease Society of America and the American College of Gastroenterology recommend empirical antibacterial therapy for travellers' diarrhoea. Because therapy is directed largely at relieving symptoms and minimising inconvenience, the chosen antibacterial should ideally be both efficacious and pose a low risk of adverse effects. This review discusses the safety and tolerability of rifaximin in the treatment of travellers' diarrhoea, with a focus on data from controlled clinical trials. Data were obtained from a MEDLINE search using the key word 'rifaximin' with no date limits and from the rifaximin New Drug Application submitted to the US FDA for approval to market rifaximin in the US.Currently, the antibacterials considered as standard treatment for travellers' diarrhoea are systemically absorbed, carry defined risks of adverse effects, and have many uses other than the treatment of enteric disease. The minimally absorbed (<0.4%) oral antibacterial rifaximin constitutes a non-systemic approach to antidiarrhoeal therapy that should overcome some of the limitations of current antibacterials used for travellers' diarrhoea. Rifaximin is differentiated from these, and most other antibacterials, by having a tolerability profile comparable with that of placebo and minimal potential for drug interactions. To date, clinically relevant resistance to rifaximin has not been observed. As the first nonabsorbable antibacterial to be marketed for travellers' diarrhoea, rifaximin should help to change the management paradigm for travellers' diarrhoea and other gastrointestinal illnesses from a systemic approach to a predictably safer, non-systemic approach.
Anti-Infective Agents↗
A randomized, double-blind, multicenter study of rifaximin compared with placebo and with ciprofloxacin in the treatment of travelers' diarrhea.
Rifaximin was compared with placebo and ciprofloxacin for treatment of travelers' diarrhea in a randomized, double-blind clinical trial. Adult travelers (N = 399) consulting travel clinics in Mexico, Guatemala, and India were randomized to receive rifaximin 200 mg three times a day, ciprofloxacin (500 mg two times a day and placebo once a day), or placebo three times a day for 3 days. Patients recorded in daily diaries the time and consistency of each stool and documented symptoms for 5 days after treatment. Stool samples were collected for microbiologic evaluations before and after treatment. The median time to last unformed stool (TLUS) in the rifaximin group (32.0 hours) was less than one half that in the placebo group (65.5 hours; P = 0.001; risk ratio 1.6; 95% confidence interval 1.2, 2.2; primary efficacy endpoint). The median TLUS in the ciprofloxacin group was 28.8 hours (P = 0.0003 versus placebo; P = 0.35 versus rifaximin). Rifaximin was less effective than ciprofloxacin for invasive intestinal bacterial pathogens. Oral rifaximin is a safe and effective treatment of travelers' diarrhea caused by noninvasive pathogens.
Adolescent↗
Nonantimicrobial agents in the prevention and treatment of traveler's diarrhea.
Among the nonantimicrobial agents that are available and useful for the prevention of traveler's diarrhea are bismuth subsalicylate-containing preparations, which can provide a rate of protection of up to 65% when taken 4 times daily. In one study, the probiotic Lactobacillus GG was found to provide 49% protection against traveler's diarrhea, but results with this agent and other probiotics have been highly variable and geographically inconsistent. Tannin albuminate plus ethacridine lactate provided 36% protection, but it is not widely available. Among the nonantimicrobial agents that are available and useful for the treatment of traveler's diarrhea are bismuth subsalicylate-containing preparations, which reduce the passage of loose stools by 16%-18%. The antisecretory and antimotility agent loperamide reduces the passage of loose stools by approximately 50% and has been especially useful, in combination with antimicrobial agents, in reducing the total duration of posttreatment diarrhea to a matter of hours.
Antidiarrheals↗
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.
Adolescent↗
A randomized, double-blind, placebo-controlled trial of rifaximin to prevent travelers' diarrhea.
BACKGROUND: Travelers' diarrhea causes substantial morbidity and postinfectious irritable bowel syndrome. OBJECTIVE: To evaluate nonabsorbable rifaximin for prevention of travelers' diarrhea. DESIGN: Randomized, double-blind, placebo-controlled clinical trial. SETTING: Guadalajara, Mexico. PARTICIPANTS: U.S. students. INTERVENTION: On arrival in Guadalajara, Mexico, 210 U.S. adults received rifaximin (200 mg/d, 200 mg twice daily, or 200 mg 3 times daily) or placebo for 2 weeks. MEASUREMENTS: Participants were followed daily for 3 weeks for enteric disease and symptoms and daily for 5 weeks for drug side effects. Changes in intestinal coliform flora were studied. RESULTS: Travelers' diarrhea developed in 14.74% of participants taking rifaximin and 53.70% of those taking placebo (rate ratio, 0.27 [95% CI, 0.17 to 0.43]). Rifaximin provided 72% and 77% protection against travelers' diarrhea and antibiotic-treated travelers' diarrhea, respectively (P < 0.001 for both), and all rifaximin doses were superior to placebo. In the groups that did not report travelers' diarrhea, rifaximin significantly reduced the occurrence of mild diarrhea (P = 0.02) and moderate and severe intestinal problems (P = 0.009 for pain or cramps; P = 0.02 for excessive gas). Rates of adverse events were comparable in the rifaximin and placebo groups. Minimal changes in coliform flora were found during rifaximin therapy. LIMITATIONS: Rifaximin safely prevented travelers' diarrhea in Mexico, where most cases are caused by diarrhea-producing Escherichia coli. A study is needed in Asia to determine whether rifaximin can prevent diarrhea caused by invasive bacterial pathogens. CONCLUSIONS: Rifaximin prevents travelers' diarrhea with minimal changes in fecal flora, and more liberal chemoprophylaxis against this disease should be considered. Future studies should evaluate whether rifaximin is effective in preventing postinfectious irritable bowel syndrome.
Adult↗
Rifaximin in the treatment of infectious diarrhea.
Rifaximin matches the criteria for an ideal agent for the treatment of infectious diarrhea. It has excellent activity against a broad range of enteropathogens. It is nonabsorbable, which may help explain its excellent side effect profile and lack of emergence of resistance because of high stool levels that are not likely to reach subinhibitory levels before the target Gram-negative bacilli are killed. It has shown excellent efficacy in numerous clinical trials of bacterial diarrhea. Because of the lack of systemic absorption and minimal adverse reactions, rifaximin should be useful in treating hosts such as pregnant women in whom the currently favored fluoroquinolones are contraindicated. Uses limited to enteric indications and its inherently low propensity to induce sustainable resistance among Gram-negative flora favor the sustained usefulness of rifaximin in the treatment of enteric infectious syndromes.
Adult↗
Fatal amphotericin B overdose due to administration of nonlipid formulation instead of lipid formulation.
The toxicity of amphotericin B deoxycholate has led to increased preference for lipid formulations with more favorable safety profiles. However, the primary use of lipid formulations is cost prohibitive, and many hospital formularies list both lipid and nonlipid formulations. A dispensing and administration error that caused amphotericin B deoxycholate to be given instead of liposomal amphotericin B related in a fatality. Measures to prevent confusion and aid in understanding the differences between lipid and nonlipid formulations of amphotericin B should be implemented.
Adult↗
The role of diet in the treatment of travelers' diarrhea: a pilot study.
A pilot study was performed to compare the effects of a restricted physiologic diet in 48 subjects with those of an unrestricted diet in 57 subjects on the duration and symptoms of acute travelers' diarrhea among US adults being treated with an antimicrobial agent in Mexico. Restricted physiologic diet was defined as the avoidance of certain foods during diarrheal illness, as specified in limited published literature. The mean duration of diarrhea (37 vs. 33 h) and clinical symptoms were similar between those practicing the restricted diet and those practicing unrestricted diets. These results suggest that restricting diet during treatment of travelers' diarrhea with an antimicrobial agent is not associated with improvement of clinical symptoms or with decreased duration of diarrhea. However, a much higher number of subjects would need to be studied to prove this point statistically.
Adult↗
Enteroaggregative Escherichia coli diarrhea in travelers: response to rifaximin therapy.
BACKGROUND AND AIMS: We have recently shown that enteroaggregative Escherichia coli (EAEC) strains commonly cause travelers' diarrhea. The study was designed to determine whether U.S. travelers with EAEC diarrhea responded to rifaximin therapy. METHODS: In a multicenter placebo-controlled clinical trial of travelers' diarrhea without non-EAEC pathogens we evaluated 2 doses of rifaximin. EAEC was sought in stool samples in enrolled subjects by HEp-2 cell assay. Response to rifaximin (both groups combined) and placebo were evaluated in EAEC-positive and EAEC-negative patient groups. RESULTS: Compared with placebo, rifaximin shortened the postenrollment illness in travelers with EAEC diarrhea (median, 22 vs. 72 hours; P = 0.03). In subjects with EAEC-negative diarrhea, the median duration of post-treatment diarrhea was shorter with rifaximin (33 hours) than with placebo (52 hours), but this difference was not significantly different (P = 0.14). CONCLUSIONS: Improvement of EAEC-mediated diarrhea with antibiotic treatment supports the pathogenicity of this organism in travelers to developing countries. The study provides information on the value of the poorly absorbed drug rifaximin in therapy of travelers' diarrhea.
Anti-Infective Agents↗
Azithromycin found to be comparable to levofloxacin for the treatment of US travelers with acute diarrhea acquired in Mexico.
Increased drug resistance among enteropathogens is an emergent problem in travelers' diarrhea. This randomized, double-blind trial was conducted in Guadalajara, Mexico, during the summers of 1999-2001 to compare azithromycin with levofloxacin for the treatment of travelers' diarrhea. A total of 217 US adults were randomized to receive a single oral dose of azithromycin (1000 mg; 108 persons) or levofloxacin (500 mg; 109 persons), with a follow-up period of 4 days. Three patients in each group dropped out of the study. The median time between initiation of therapy and passage of the last unformed stool (azithromycin group, 22.3 h; levofloxacin group, 21.5 h) and the number of unformed stools passed during the 4-day follow-up period (azithromycin group, 6.5; levofloxacin group, 5.5) were similar. Treatment failure occurred in 10 patients (9.5%) receiving azithromycin and 8 patients (7.5%) receiving levofloxacin. Possible minor, self-limiting adverse events occurred in 57 patients in each treatment group. Azithromycin was found to be a safe and effective alternative to levofloxacin for the treatment of acute travelers' diarrhea in US adult travelers to Mexico.
Adult↗
Travellers' diarrhoea.
Risk of travellers' diarrhoea is about 7% in developed countries and 20-50% in the developing world. Options for prevention include education and chemoprophylaxis. Vaccination is a promising but incomplete option. Achieving behaviour modification of food and water choices among tourists is difficult. Bismuth subsalicylate (BSS)-containing compounds are about 62% effective in the prevention of travellers' diarrhoea. Antibiotics are about 84% effective in preventing travellers' diarrhoea. Routine prophylaxis of travellers' diarrhoea, especially with antibiotics, should be discouraged. Oral rehydration is generally important in the treatment of diarrhoea, but travellers' diarrhoea is only infrequently dehydrating in adults. The addition of oral rehydration solutions confers no additional benefit to loperamide in the treatment of travellers' diarrhoea in adults. Presently, the most active of the antibiotics routinely available for treatment are members of the fluoroquinolone group. Antibiotics that are not absorbed such as aztreonam and a rifampicin-like agent, rifaximin, are both effective. The latter might become a therapy of choice once it is routinely available, due to predictably less adverse reactions with a non-absorbed antibiotic. Preliminary results with azithromycin look very promising. Less severe disease can be treated with a variety of non-antibiotic agents (e.g. BSS-containing compounds, loperamide and a calmodulin inhibitor, zaldaride). The combination of an antibiotic and loperamide is superior to treatment with either agent alone in a several studies and is arguably the treatment of choice for distressing travellers' diarrhoea.
Adult↗
Travellers with pre-existing medical conditions.
Medical conditions that influence travel include those that compromise the immunity of the traveller and chronic underlying diseases or infirmities. The former includes HIV, transplantation, malignancy and its treatment, IgA deficiency, asplenia and use of immunocompromising drugs like corticosteroids. Chronic conditions include diabetes mellitus, end stage renal disease, diseases associated with compromised cardiac or pulmonary function and certain gastrointestinal diseases including cirrhosis. This review includes practical approaches to each of these conditions with attention to risk assessment and avoidance, vaccination when appropriate and not a risk to the compromised host, and arming the traveller with self-therapy and chemoprophylaxis. Since travellers with underlying conditions are often taking various medications the travel health practitioner must be alert for possible drug/drug interactions and must adjust dosages depending on the level of compromised renal or hepatic function. Finally, education of such travellers is paramount; they must understand that risk avoidance is critical and preventative modalities such as vaccination and chemoprophylaxis are never 100% efficacious.
Diabetes Mellitus↗
Therapy of travelers' diarrhea with rifaximin on various continents.
OBJECTIVE: Our aim was to compare the efficacy and safety of rifaximin, a virtually nonabsorbed antibiotic, 600 and 1200 mg per day, with placebo in patients with travelers' diarrhea. METHODS: This was a multicenter, 1:1:1 randomized, parallel-group, double-blind study, conducted in Antigua, Guatemala; Guadalajara and Morelia, Mexico; and the coast of Kenya north and south of Mombasa. Adult patients with acute travelers' diarrhea were recruited; exclusion criteria included primarily medication that could influence the outcome. Subjects were treated for 3 days, three times daily; follow-up lasted 5 days. For each 24-h period, the subjects completed a diary card. Pre- and posttreatment stool, blood, and urine samples were assessed. RESULTS: Among the 380 volunteers, median time to the last unformed stool was 32.5 and 32.9 h in both rifaximin groups, compared with 60.0 h with placebo (p = 0.0001). Also, secondary clinical outcome measures were favorably influenced by the active agent. No relevant side effects were reported. CONCLUSION: Rifaximin is efficacious and safe for treatment of travelers' diarrhea at daily doses of 600 mg or higher.
Adolescent↗
Enteric pathogens in Mexican sauces of popular restaurants in Guadalajara, Mexico, and Houston, Texas.
BACKGROUND: The transmission of traveler's diarrhea is primarily foodborne. OBJECTIVE: To examine the level of microbial contamination of tabletop sauces found in Mexican-style restaurants. DESIGN: Cross-sectional study of Mexican sauces. SETTING: Mexican restaurants in Guadalajara, Mexico, and Houston, Texas, during the summer of 1998. MEASUREMENTS: 71 sauces from Guadalajara and 25 sauces from Houston were examined. The number of sauces contaminated with Escherichia coli, the median number of E. coli colonies per gram of sauce, and enteropathogens were identified. RESULTS: 47 of 71 sauces from Guadalajara were contaminated with E. coli versus 10 of 25 sauces from Houston (P = 0.03); the median number of E. coli colonies per gram of sauce was 1000 in the Guadalajara sauces versus 0.0 in the Houston sauces (P = 0.007). Among sauces from Guadalajara tested for diarrheogenic E. coli, 4 of 43 sauces contained enterotoxigenic E. coli and 14 of 32 contained enteroaggregative E. coli. CONCLUSIONS: Contamination with E. coli was common in samples of Mexican tabletop sauces from Guadalajara restaurants. These sauces commonly contained enteric pathogens.
Cross-Sectional Studies↗
Natural history of enteroaggregative and enterotoxigenic Escherichia coli infection among US travelers to Guadalajara, Mexico.
The natural history of enteroaggregative Escherichia coli (EAEC) and enterotoxigenic E. coli (ETEC) infection was studied among 40 US travelers who provided weekly stool samples for 4 weeks after arrival in Mexico. At enrollment, 5 subjects were colonized by EAEC and 3 by ETEC. During the first 2 weeks after enrollment, 12 developed EAEC diarrhea, 7 developed ETEC diarrhea (5 with mixed EAEC/ETEC diarrhea), 13 had EAEC colonization, and 7 had ETEC colonization. During the third and fourth weeks, 4 experienced EAEC diarrhea, 2 experienced ETEC diarrhea (1 with mixed EAEC/ETEC diarrhea), 31 had EAEC colonization, and none had ETEC colonization. Plasmid DNA analysis showed a high degree of heterogeneity among EAEC isolates. Symptomatic EAEC infection occurred early after arrival in Guadalajara, Mexico, and was as common as ETEC infection. Asymptomatic EAEC infection was recurrent.
Adolescent↗
Enterotoxigenic Escherichia coli as cause of diarrhea among Mexican adults and US travelers in Mexico.
BACKGROUND: Enterotoxigenic Escherichia coli (ETEC) is the most common pathogen identified in travelers to Mexico with diarrhea. There have been few recent studies looking at the etiology of diarrhea in travelers compared with the local resident population. METHODS: We compared enteric pathogens isolated in two populations experiencing acute diarrhea acquired in Guadalajara, Mexico and also compared clinical illness caused by the principal pathogen, ETEC. RESULTS: A single and 2 enteropathogens were detected in 107 (23%) and 8 (2%), respectively, of 457 Mexicans in 1995 and 1997, and 37 (29%) and 2 (2%), respectively, of 127 US adults in 1997. The most common pathogen was ETEC in both groups (11% of Mexican, 19% of US adults), although more common in the US travelers group (p =.0017). Shigella spp and Cryptosporidium spp were less common in the Mexican (<1% and <1%, respectively) than in the travelers group (6% and 3%, respectively) (p <.001 and p =.002, respectively). Entamoeba histolytica was more often found in the Mexican group (4% Mexican, 0% US adults; p =.027). CONCLUSION: ETEC is the most common pathogen among travelers and Mexican residents in this study. The duration of untreated diarrhea due to ETEC was significantly shorter among Mexicans (49 hours in Mexican, 94 hours in US adults; p =.0004), as was the average number of unformed stools passed over 4 days (Mexicans 8.8 versus travelers 17.9 stools; p =.0009
Adult↗