Unwelcome Guests

These types of guests seem to be a given in life. Whether it’s someone you can’t stand crashing your BBQ or the taxman paying a surprise visit to your place of business or the drunken relatives during the holidays season, these encounters will never be void from your life. The only question that might remain is whether or not you had any hand in deliberately or inadvertently bringing these instances upon yourself, and by the time you per chance come upon that particular answer more than likely the damage has started to fully precipitate itself or it’s already been done. The best you can ever hope for is to minimize these scenarios from ever happening again…good luck with that.Recently I had the disturbing fortune to read an article in the NEJM (New England journal of medicine 10/8/05) about the increasing occurrences of infections of a bacteria called Clostridium difficile. The most disturbing part is it’s manifesting itself now in a strain that is showing resistance to some of the most commonly effective antibiotics that we travelers use for what is termed “Travelers diarrhea”, most notably Ciproflaxin (Cipro) and Levoflaxin (Levaquin). I don’t know about you all, but I feel all but naked without one of these two in my kit. This disturbed me. It also intrigued me to look into what this might bode for all of us who enjoy going to developing countries for our shits (pun intended) and giggles. So I decided to dig deeper and utilize some of the resources available to me and I learned quite a bit. More than I ever really wanted to know, but informative all the same.The smaller but more serious issue of drug resistant bugs is usually due to two major factors, drug overuse and the simple fact that most people who take the drugs never finish the complete course thus enabling the microbe to mutate into a more virulent strain. The larger issue though is the subject of “Travelers diarrhea” in general, cause, effect, prevention and all it entails. I’ll focus primarily on these subjects.

Let’s face it whom amongst us has not encountered this special little gift from our travels? Personally I’ve been uncannily lucky, although it never seems to fail that I’ll be spending at least some time and effort taking care of my travel companions because they’ve fallen victim to this all too common affliction. Even my last trip I ended up playing doctor for a few of the pensioners along for the ride. My motivation is purely selfish though. I’d be damned if I was going to let their illnesses fubar my trip.

First off, diarrhea is the most common medical problem-affecting travelers to developing countries. Up to 50% of these travelers can expect to get sick during a two-week stay and about 20% will have to spend some time in bed. And the risk is not entirely uniform throughout the world. The Caribbean and less developed countries in Europe are obviously not going to be as bad as Asia, Africa or Latin America. Food is also the most common vector for transmission so it makes sense that about 50% of all cases are from Escherichia coli, or E coli. There is a veritable multitude of reasons why this is so. Everything from the most obvious like unhygienic food handling to the more obscure like using human fecal matter as vegetable fertilizer, and yes that fly and grubby street vendor that just interacted with your kebab can also be guilty as charged. Damn those vendors too, that whole peel the fruit thing might not even keep you safe as it’s not unheard of for them to inject that fruit with contaminated water to increase the weight, hence also it’s value! Take heart though as sometimes it’s extremely difficult to discern TD (Travelers diarrhea) from food poisoning caused by a heat stable toxin producing bacteria like Staphylococcus or Clostridium. The upside with those though is they tend to become symptomatic within 1-6 hours as opposed to TD bacterial invasions that usually are up to 16 hours. And to add to the fun there are also viruses such as Rota and Norwalk that can mimic these symptoms but they tend to run their course on their own in all but the most vulnerable, and with all these they tend to be old or the very young or the immunocompromised. It would also be unfair to leave out Protozoa from the mix, Giardia and Cryptosporidium being the most common. You’ll know it’s these little critters when the symptoms last for a while and they don’t respond to antibiotics.

Hey what about water? you’re probably asking because after all you’re always told, “Don’t drink the water!” Strangely enough it’s actually a lesser cause generally speaking because the amount of bugs in the water tend to be more diluted than the concentration on foodstuffs. This is not to say you should stop tying the little red ribbon on your hotel room faucet to remind you not to drink from it. Bottled water is of course the way to go, just make sure the seal on it looks untampered. Beer and soda are safe because their acidity and brewing processes usually create an unfavorable environment for the microbes to exist, just don’t enjoy them with ice. Interestingly enough there is some evidence that if you were to mistakenly brush your teeth with faucet water you might be ok as there is some proof as to the antibiotic properties of toothpaste. While swimming or swallowing shower water can be causative, the risk is lower due again to the low bug count. To the “boil it peel it” maxim you can also add the “P” one. “Peel able, packaged, purified, piping hot”

So who are these creatures of God that would deign to ruin your time abroad? Well the most common are:
E. coli
Camplyobactor jejuni

Not to mention a plethora of lesser known and less common Cholera and non-Cholera types. They are also more commonly associated in various parts of the world. E coli, Latin America, Camplybactor, SEAsia and N. Africa, and the newer Cipro resistant strains are manifesting themselves in SEAsia and the Indian sub-continent so one of the recommendations there, is to wash with plain soap and water as opposed to antibiotic soap as it will down the line hinder the resistant strains development. Even the alcohol based hand gels won’t kill the bacterial spores of these strains.

Ok you followed all the rules of thumb, and you were really careful, but damn it all, you’ve now picked up one of these bad boys somewhere somehow. Now what? Well in the past people did all sorts of stuff like prophylaxis, even taking Pepto bismol up to four times a day with some success. Nowadays the recommendation is to shy away from this tactic for the very reason resistant bugs are gaining ground. Unless you already have some sort of bad underlying medical condition the gold standard now is to use antimotility agents i.e. Imodium A-D in conjunction with Cipro, Levaquin, or Floxin (Olfloxacin) as directed on the prescription. This course usually relieves mild bouts within 24 hours or so. More sever cases could take up to 3 days of antibiotic treatment. This is not the case if it’s full blown dysentery though. A doctor should be seen in those cases or in the event of blood in stools. People, who have seizures, the pregnant or the young, 18 years of age and under, should not take Cipro. Oral rehydration and diet are an extremely important component of treatment. Commercially available mixtures and recipes are available and foods such as salted soda crackers or plain salted rice are recommended. If this treatment fails to resolve the symptoms it may be a more sever problem such as parasites or internal organ issues. A resistant strain may also be at work. Zithromax is being found to be effective with some of these in some cases. Treatment is guaranteed to get more difficult with the advent of these new strains.

The wave of the future has a few directions in which treatment will go. Non-absorbable drugs like Furoxone and Rifaximin have had some success. Bowl specific prophylaxis agents, biotherapeutic agents, and vaccine development like malaria treatments are in the exploratory stages but still pretty far away.

Ultimately as it was written in one article I read it stated, “The elimination of poverty and not new drugs will resolve the problem of endemic travelers diarrhea.”

Until then though, wash your hands, watch what you eat and drink, and keep lots of toilet paper handy.



Special thanks to:
Jim Branagh RN
Travel medicine division of The hospital of the University of Pennsylvania

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