Makindo Medical Notes

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Travellers Diarrhoea: Antibiotics given for E. coli enterohaemorrhagic fever increase the risk of Haemolytic uraemic syndrome (HUS).

About

• Affects 20-30% of travellers, often within the first week of travel.
• Typically caused by ingesting contaminated food or water.

Aetiology

• E. coli: Most common cause, especially Enterotoxigenic E. coli (ETEC), which produces toxins that cause diarrhoea.
• Campylobacter: Can present with an acute abdomen-like picture, often with bloody diarrhoea.
• Amoebic Dysentery: Causes abdominal pain and bloody diarrhoea, often seen with Entamoeba histolytica.
• Clostridium difficile: Can cause symptoms post-antibiotic treatment, including severe colitis.
• Giardia: Causes symptoms beyond 7 days, often with foul-smelling, greasy stools.
• Cryptosporidium: Symptoms can persist beyond 7 days, particularly in immunocompromised patients.
• Cyclospora: Symptoms may persist beyond 7 days, often causing relapsing episodes.

Clinical

• Diarrhoea: Watery or sometimes bloody, depending on the pathogen.
• Other Symptoms: Nausea, vomiting, abdominal cramps, fever, and signs of dehydration.
• Severe cases: May lead to complications like electrolyte imbalances and HUS with certain E. coli strains.

Investigations

• FBC: To assess for infection and signs of dehydration.
• U&E: To monitor electrolyte levels and kidney function.
• LFTs: To check for any hepatic involvement.
• CRP: Inflammatory markers may be elevated in bacterial infections.
• Stool Examination: Microscopy, culture, and PCR for ova, cysts, parasites, and bacterial pathogens.
• Colonoscopy: Consider if diarrhoea persists, to rule out other causes like IBD.

Differential

• Inflammatory Bowel Disease (IBD): Crohn's disease or ulcerative colitis can present with similar symptoms but are usually chronic and not travel-related.
• Food Poisoning: Shorter duration, more likely linked to a specific meal.
• Viral Gastroenteritis: Often shorter in duration (24-48 hours) and more self-limiting.

Prevention

• Water Safety: Avoid drinking unboiled or unbottled water. Use bottled water for drinking and brushing teeth.
• Food Safety: Avoid foods that may be washed in potentially contaminated water, such as salads, raw fruits, and vegetables.
• Hand Hygiene: Wash hands regularly with soap, especially before eating.

Prophylaxis

• Antibiotic prophylaxis with Ciprofloxacin or Metronidazole may be considered for certain groups:
• Individuals with ileostomy or other bowel surgeries.
• Immunocompromised patients (e.g., HIV/AIDS, transplant patients).
• Patients with chronic kidney disease (CKD).

Management

• Hydration: Rehydrate with clean water or oral rehydration solutions. Bottled water is often preferred when the source of water is unclear.
• Antibiotics: Ciprofloxacin or Metronidazole may be indicated after consultation with an infectious disease specialist, especially in cases of dysentery or prolonged symptoms.
• Antimotility Agents: Loperamide can be used for mild cases but is contraindicated in cases of bloody diarrhoea or high fever.
• Post-Infection: Some patients may develop post-infectious irritable bowel syndrome (IBS) following resolution of symptoms.
• Seek Medical Attention: If symptoms worsen or dehydration becomes severe, seek medical attention for potential IV fluid therapy and further evaluation.

References

• CDC: Travelers' Diarrhea
• NHS: Travel Diarrhoea