Unwell returned traveller

Transcription

1 Unwell returned traveller Full Title of Guideline: Author (include and role): Division & Speciality: Scope (Target audience, state if Trust wide): Review date (when this version goes out of date): Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis): Changes from previous version (not applicable if this is a new guideline, enter below if extensive): Summary of evidence base this A Guideline for the Management of the Unwell Returned Traveller Dr P Venkatesan Medicine Infectious Diseases Physicians admitting adult patients to NUH Adult patients admitted to NUH New epidemiological data, new references, editorial changes Epidemiology and international experience guideline has been created from: This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date or outside of the Trust.

2 A GUIDELINE FOR THE MANAGEMENT OF THE UNWELL RETURNED TRAVELLER In the year 2016, 70.8 million trips abroad were made by UK residents, with ~15% of trips made to tropical countries. It is estimated that only a third of the latter travellers are appropriately immunised and take the correct malaria prophylaxis. Fortunately less than 5% of tropical travellers acquire illnesses sufficient to require medical attention and some of these are admitted to hospital. A. INTRODUCTION Only a small percentage of all returned travelers require hospitalisation. It is important to - identify cases of falciparum malaria, - be aware of infection control issues and - be aware of the rare possibility of a viral haemorrhagic fever eg. Ebola fever. This guideline summarises the differential diagnosis to be considered, initial investigations and management of patients. For specific diagnoses reference should be made to the relevant guidelines (malaria, traveller s diarrhea, typhoid and viral haemorrhagic fever). B. DIFFERENTIAL DIAGNOSIS The range of diagnoses to consider is described by Ryan et al (2002), Johnston et al (2009) and Thwaites (2017). 1,2,3 To date there are only two prospective, UK, adult studies of hospitalised, unwell returned travellers. 4,5 (Evidence grade 3). The range of diagnoses found is shown in the following table. London (1995) Birmingham (2000) Nottingham (2014) n=195 n=227 N=222 Malaria Gastroenteritis Self-limiting fever Hepatitis Enteric fever Other 47 (24%) 34 (15%) 61 (27%)

3 76 85% of diagnoses were accounted for by the five diagnoses shown. Other included meningitis, upper and lower respiratory tract infections, tuberculosis, urinary tract infections, sexually transmitted diseases (including acute HIV), soft tissue infection, arboviral infection and typhus. There are three common principle syndromes of presentation - Fever + other symptoms - Diarrhoea - Jaundice Fever + other symptoms - Always consider malaria, especially falciparum malaria, which usually presents within 2 months of return. The key area for falciparum malaria is sub-saharan Africa, especially West Africa, but it occurs elsewhere in the world as well. - Enteric fever (typhoid and paratyphoid) may give no localising symptoms and usually presents within 3 weeks of return. - On review from head to toe associated symptoms may localise the infection to a particular site, but an atypical pneumonia may have no respiratory symptoms or signs. - Multi-system upset is most importantly due to complicated falciparum malaria, but may also be caused by arboviruses (e.g. Dengue fever 5 ), leptospirosis or typhus. Also beware of acute HIV seroconversion illness. Viral haemorrhagic fevers These should be suspected if - a patient has left an area where an epidemic is taking place, be it rural or urban, with any symptoms, be they mild or severe, - or a rural part of an endemic area, for clinical features - particularly if they are a health care worker or had contact with confirmed cases - and have returned within the past 21 days - or if they are a laboratory worker handling viruses causing VHF.

4 Weblink Up to date information on infections country by country worldwide or of disease outbreaks can be obtained from WHO ( Travel Health Pro ( or fitfortravel ( C. INVESTIGATIONS Investigations to be considered on admission include - FBC + malaria blood films (the laboratory will also do malaria antigen tests) - If the first malaria blood film is negative and there is a strong suspicion of malaria the film should be repeated - U&Es, LFTs, Glucose - MSU - Blood cultures - CXR (given the possibility of an atypical pneumonia) - Stool for M,C&S + OCP if diarrhoea is present (three specimens) - Further serological tests should be guided by initial findings Any sick patients (who might turn out to have complicated falciparum malaria) should also have - Clotting screen - Arterial blood gases (if oxygen saturation reduced) Patients with eosinophilia are more likely to present in the outpatient setting. There are published guidelines on the differential for eosinophilia. 6 Any patient who has received hospital care outside the UK is at risk of carrying Carbapenemase Resistant Enterobacteriaceae (CRE), therefore strict active screening of any patient transferred across borders into a healthcare facility in the United Kingdom is advised. All patients meeting the following criteria are deemed at risk of having CRE and therefore should be screened on admission:

5 - any patient transferred directly from a healthcare facility abroad - any patient who has been recently (within the last 12 month) hospitalised abroad - any patient who is admitted with problems related to a recent hospitalisation abroad (this includes emergency and elective admissions) - Any patients with a previous history of CRE For screening, the following samples should be taken: i. Stool sample - If it is not possible to obtain a stool sample, a rectal swab can be sent ii. iii. Wound swab - any surgical wounds, leg ulcers, breaks in skin or other lesions Swabs from manipulated sites - lines, cannulae, tracheostomy, percutaneous endoscopic gastrostomy (PEG) and drain sites. All specimens should be labelled on the form clearly as CRE screening and notify the Microbiology laboratory if multiple specimens are being sent. A sample can be confirmed negative in 24 hours, however a positive sample can take 3-4 days. D. MANAGEMENT - If in doubt contact the Infectious Disease team. Out of hours the on call SpR pr Consultant can be contacted via switchboard. - For any falciparum malaria or sick patient contact the Infectious Disease team. - Unless a non-contagious diagnosis has been made, patients should preferably be admitted to a sideroom. E. NURSING ISSUES 1) Samples to be collected may include - sputum for M,C&S (and perhaps AFB) - MSU with urinalysis - Stool if diarrhoea present for M,C&S, OCP (which stands for ova, cysts and parasites)

6 2) Observations include - standard temperature, pulse, BP at 4-6 hourly intervals, unless otherwise indicated - in addition oxygen saturations should be monitored if the patient is short of breath 3) Enteric, respiratory or blood precautions may be required References 1. Ryan ET et al. Illness after international travel. New England Journal of Medicine 2002;347: Johnston V et al. Fever in returned travelers presenting in the United Kingdom: recommendations for investigation and initial management. Journal of Infection 2009;59: Thwaites GE, Day NPJ. Approach to fever in the returning traveller. New England Journal of Medicine 2017;376: Doherty JF, Grant AD, Bryceson ADM. Fever as the presenting complaint of travellers returning from the tropics. Q J Med 1995;88: Venkatesan P, Dedicoat M. In Travel Medicine and Migrant Health. Eds Lockie C et al, Churchill Livingstone, Edinburgh Simmons CP et al. Current concepts : Dengue. New England Journal of Medicine 2012 ;366: Checkly AM et al. Eosinophilia in returning travellers and migrants from the tropics: UK recommendations for investigation and initial management. Journal of Infection 2010;60:1-20.

7 AUDIT FORM Date : Please print off the guideline together with this audit form. Place the audit form on the front of the notes and complete the form at discharge or when dictating the discharge summary. On completion please return this audit form to Dr Venkatesan. Hospital number : Unwell Returned Traveller Specific Diagnosis if made: Country/ies visited : History and examination adequate Investigations as per guideline Management as per guideline Discharge and follow up as per guideline Outcomes (please tick) Full recovery Complications (please state) Death (please give details) Near misses / Serious incidents (please detail) No Could we have done better? (please detail) No