FOODBORNE INFECTIONS. Caroline Charlier-Woerther March 2017

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1 FOODBORNE INFECTIONS Caroline Charlier-Woerther March 2017

2 LEARNING OBJECTIVES Know the pathogens involved in diarrheas Know the basics of management of diarrhea Know the main patterns of listeriosis and how to diagnose them Recognize and treat C. difficile Recognize and treat amoebiasis

3 FOODBORNE INFECTIONS Pathogens Clinical patterns Complications Diagnosis Basics of treatment Listeriosis, C. diff and amoebiasis

4 FOODBORNE INFECTIONS Infections of food origin Diarrhea +/- Other symptoms Meningitis, fetal loss Bacteremias, neurotransmission blockade Single individual/ collective infections Frequent : 1/6 US Citizen / year

5 FOODBORNE INFECTIONS PATHOPHYSIOLOGY Release of a toxin targeting the enterocyte enhanced water and electrolytes secretion watery diarrhea Vibrio cholerae Enterotoxinogenic E. coli Staphylococcus aureus

6 FOODBORNE INFECTIONS PATHOPHYSIOLOGY Destruction of the enterocytes Dysentery : pus/ blood/ mucoid diarrhea/ fever/cramps Shigella sp., Entamoeba histolytica Dissemination beyond the digestive tract Enterocytes macrophages mesenteric lymph node beyond Fever, bacteremia Salmonella sp., Yersinia sp. All = entero-invasive mechanism

7 FOODBORNE INFECTIONS AGENTS ASSOCIATED WITH DIARRHEAS > 250 PATHOGENS DESCRIBED Agent Bacteria Entero-invasive Toxinic Viruses Parasites Salmonella sp.*, Shigella sp., Campylobacter sp., Yersinia sp., Enteroinvasive or enterohemorragic E. coli, Clostridium difficile, Listeria monocytogenes V. cholerae, Clostridium perfringens, Staphylococcus aureus, Enterotoxinogenic E. coli Norovirus, Rotavirus, Enterovirus, Adenovirus Entamoeba histolytica histolytica Giardia intestinalis Salmonella typhi and non typhoidal Salmonella

8 Agent Bacteria Entero-invasive MOST FREQUENT AGENTS Salmonella sp.*, Shigella sp., Campylobacter sp., Yersinia sp., Enteroinvasive or enterohemorragic E. coli, Clostridium difficile, Listeria monocytogenes Toxinic Viruses Parasites V. cholerae, Clostridium perfringens, Staphylococcus aureus, Enterotoxinogenic E. coli Norovirus, Rotavirus, Enterovirus, Adenovirus Entamoeba histolytica histolytica Giardia intestinalis USA CDC data Norovirus 5,400,000 cases / year Non typhoidal salmonella 1,000,000 cases / year Clostridium perfringens 950,000 cases / year Campylobacter 850,000 cases / year S. aureus 250,000 cases / year

9 Bacteria Entero-invasive Toxinic Viruses Parasites MOST SEVERE AGENTS Salmonella sp.*, Shigella sp., Campylobacter sp., Yersinia sp., Enteroinvasive or enterohemorragic E. coli, Clostridium difficile, Listeria monocytogenes V. cholerae, Clostridium perfringens, Staphylococcus aureus, Enterotoxinogenic E. coli Norovirus, Rotavirus, Enterovirus, Adenovirus Entamoeba histolytica histolytica Giardia intestinalis USA CDC data : Annual deaths Listeriosis : 255 deaths among 650 reported cases > 35% mortality Salmonella : 378 deaths among 1,000,000 cases Norovirus : 150 deaths among 5,000,000 cases

10 1. Identify emergencies Dehydration Sepsis and bacteremia Occlusion in severe colitis MANAGEMENT Febrile diarrhea in a traveller returning from malaria area always think of malaria

11 MANAGEMENT 2. Diagnosis Confirm diarrhea ( > stools /day) Exclude non infectious diarrhea Identify diarrhea associated with non enteric infectious diseases : malaria/ leptospirosis/ pyelonephritis/legionellosis

12 MANAGEMENT 2. Diagnosis Collect clinical data 3 patterns associated with distinct pathogens Dysentery : blood, pus, mucoid diarrhea (fever) Watery cholera-like : diarrhea, usually no fever Gastroenteritis-like : diarrhea, vomiting, (fever) : no orientation

13 MANAGEMENT 2. Diagnosis Collect clinical data 3 patterns associated with distinct pathogens Acute / chronic infection? Collective infection? Type of food consumed/ recent antibiotic uptake? Recent travel in a tropical area? Background? (pregnancy? IC?)

14 2. Diagnosis MANAGEMENT Biological tests 1. stool culture If any complication/ dysentery/ collective infection / return from tropical area/ ID patients 2. stool test for C. difficile toxin If recent antibiotic exposure 3. virological test in the stool (ELISA) If complication / ID 4. stool samples for parasites If return from tropical area / ID patients 5. blood cultures if fever 6. (rectosigmoido-/ colonoscopy in case of proctitis / colitis)

15 MANAGEMENT 3. Principles of treatment Rehydratation Antibiotics in invasive diarrheas Fluoroquinolones Azithromycine Avoid anti-peristaltic drugs like loperamide

16 MANAGEMENT 3. Principles of prevention Wash hands Cook food/ peel food Water : filtered or boiled or encapsulated

17 FOODBORNE INFECTIONS AGENTS ASSOCIATED WITH DIARRHEAS > 250 PATHOGENS DESCRIBED Agent Bacteria Entero-invasive Toxinic Viruses Parasites Salmonella sp.*, Shigella sp., Campylobacter sp., Yersinia sp., Enteroinvasive or enterohemorragic E. coli, Clostridium difficile, Listeria monocytogenes V. cholerae, Clostridium perfringens, Staphylococcus aureus, Enterotoxinogenic E. coli Norovirus, Rotavirus, Enterovirus, Adenovirus Entamoeba histolytica histolytica Giardia intestinalis Salmonella typhi and non typhoidal Salmonella

18 CLOSTRIDIUM DIFFICILE Asymptomatic carriage of non-toxinogenic C. difficile : 3% adult population Toxinogenic C. difficile Antibiotic exposure Acquisition of C. difficile Secretion of CD toxins Watery diarrhea / low fever Pseudomembranous diarrhea

19 Watery diarrhea Pseudomembranous colitis Fever, abdominal cramps High leukocytes count Bloody / mucoid diarrhea CLOSTRIDIUM DIFFICILE Diagnosis toxin in the stool in both membranes on the colic mucosal lining

20 4 types of complications Dehydration Septic shock Colic perforation +++ Recurrence in 20% of cases CLOSTRIDIUM DIFFICILE Treatment Stop antibiotics if possible Metronidazole/ vancomycine PO/ fidaxomycin

21 OTHER INVASIVE ENTERIC BACTERIA Non typhoidal Salmonella Eggs / meats Incubation : 36h Diarrhea / vomiting / high fever (no blood) Campylobacter jejuni Poultry Incubation 1-3 days Bloody stool / cramps / fever

22 OTHER INVASIVE ENTERIC BACTERIA Yersinia enterocolitica Incubation 4-6 days Milk/ meat (pork) Fever ++ / bloody stool / cramps Children may be confused with appendicitis 2% reactive arthritis Erythema nodosum

23 LISTERIOSIS Gram positive rod Able to multiply at 4 C Not killed by freezing Hemolysis Zoonosis Human infections rare but severe

24 LISTERIOSIS 1. Gastro-enteritis Febrile diarrhea Immunocompetent patients Incubation 20H 2. Septicemia Mostly immunocompromised (cellular immune defects, alcohol, corticosteroids, older patients) : 40% mortality 3. Neurological infection meningoencephalitis : 30% mortality 4. Infection in pregnancy CharlierLID 2017

25 LISTERIOSIS 4. Infection in pregnancy Mother mild disease Fever + obstetrical signs > fever alone Fetus : not teratogenic but 20% fetal loss, 40% prematurity, 20% abnormal delivery at term Placentitis Only 5% of pregnancies go on uneventful Charlier LID 2017

26 LISTERIOSIS 4. Infection in pregnancy Diagnosis Maternal blood cultures Placenta cultures Any fetal/ neonatal cultures Treatment Amoxicillin++ cephalosporins ineffective+++ Pre-emptive treatment of any unexplained maternal fever

27 LISTERIOSIS PREVENTION Avoid raw milk Avoid soft cheese Avoid meat spreads and patés Recook ready to eat food until steaming hot Wash the refrigerator Wash the hands

28 ENTEROTOXINOGENIC E. COLI Leading cause of bacterial diarrhea in tropical areas, leading cause of diarrhea in the returning traveller 300,000,000 cases / year Watery diarrhea/ vomiting / abdominal cramps mild or no fever Healing in 2-4 days Diagnosis based on PCR detection of the toxins (not routinely done) es.dreamstime.com

29 SHIGA TOXIN-PRODUCING ESCHERICHIA COLI Various serogroups involved O157:H7, O104:H4, O121 etc. All produce a toxin similar to the toxin produced by Shigella dysenteriae Bloody stool Increased risk of hemolytic and uremic syndrom Diagnosis : PCR in the stool

30 STAPHYLOCOCCUS AUREUS Short incubation < 4hours Heat-stable enterotoxin S. aureus transmitted by an asymptomatic carrier or a skin lesion Manipulated food Vomiting / diarrhea no fever

31 CLOSTRIDIUM PERFRINGENS Short incubation 6-24 hours Abdominal cramps and diarrhea, no vomiting Contaminated meat / sauce ++ Poor storage conditions Collective food

32 CLOSTRIDIUM BOTULICUM Anaerobic gram positive rod Nerve toxin 3 forms Home-canned food foodborne Ingestion of spores infant botulism Infection of a wound wound botulism

33 Blockade of neurotransmission Symptoms Double vision, blurred vision, drooping eyelids, slurred speech, difficult swallowing, dry mouth, muscle weakness If untreated, progression to paralysis of the respiratory muscles, arms, legs, and trunk. Incubated 1-2 days CLOSTRIDIUM BOTULICUM Diagnosis : clinical features (toxin in reference centers) Treatment : supportive (recuperation within wks/mths)

34 Vibrio cholerae : gram negative bacillus Endemic/ epidemic in tropical areas India/ Central America/ Africa 3-5,000,000 cases / year 150,000 deaths Not travellers CHOLERA Reservoir = people and aquatic sources like brackish waters and estuaries (global warming!!)

35 CHOLERA Short incubation < 1d Clinical presentation Nothing : 75% Among symptomatic cases Mild diarrhea = 80% Profuse watery diarrhea (10l/d), no fever = 20% so only <4% of global cases Diagnosis : stool examination and culture Vaccination confers partial protection Antibiotic treatment (cyclines) and rehydratation

36 FOODBORNE INFECTIONS AGENTS ASSOCIATED WITH DIARRHEAS > 250 PATHOGENS DESCRIBED Agent Bacteria Entero-invasive Toxinic Viruses Parasites Salmonella sp.*, Shigella sp., Campylobacter sp., Yersinia sp., Enteroinvasive or enterohemorragic E. coli, Clostridium difficile, Listeria monocytogenes V. cholerae, Clostridium perfringens, Staphylococcus aureus, Enterotoxinogenic E. coli Norovirus, Rotavirus, Enterovirus, Adenovirus Entamoeba histolytica histolytica Giardia intestinalis Salmonella typhi and non typhoidal Salmonella

37 VIRAL DIARRHEA IMMUNOCOMPETENT Children ROTAVIRUS Spring / summer High risk of dehydration if < 2 years Vaccine available in France Adults NOROVIRUS Viral identification possible in the stool (not routinely performed)

38 AMEBIASIS Protozoan parasite (division in the host) Entamoeba histolytica histolytica Tropical areas with poor sanitary conditions

39 AMEBIASIS Orofecal infection : cysts eliminated in the stool ingested trophozoites that invade the mucosal lining Human reservoir Clinical presentation Asymptomatic : 80% Loosy stool and abdominal cramps +++ Bloody stools and abdominal cramps, no fever colitis

40 AMEBIASIS Extradigestive infection Liver+++ FEVER, enlarged and tender liver Unique 2/3 > multiple abcesses 80% right lobe rad-log. blogspot.com -

41 Diagnosis Colitis : stool samples AMEBIASIS The pathogenic Entamoeba histolytica is characterized by ingested erythrocytes in the trophozoite

42 AMEBIASIS Diagnosis Stool samples for colitis Serology for liver disease False negative < 7 days of fever No parasites in the pus/ stool

43 Metronidazole 7d (colitis) 10-14d (liver) against trophozoites Tilbroquinol/tiliquinol against cysts AMEBIASIS TREATMENT Don t repeat the serology Abcesses require 2months -1 year to resolve

44 GIARDIASIS Stomach cramps Abdominal cramps Diarrhea Asymptomatic Examination of the stool for parasites Treatment : metronidazole or albendazole

45 Sources Wikimedia Commons CDC