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Food Poisoning

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Food Poisoning
Author: Roberto M Gamarra, MD; Chief Editor: Julian Katz, MD more... Updated: Feb 11, 2013

Practice Essentials
Food poisoning is defined as an illness caused by the consumption of food or water contaminated with bacteria and/or their toxins, or with parasites, viruses, or chemicals. The most common pathogens are Norovirus, Salmonella, Clostridium perfringens, Campylobacter, and Staphylococcus aureus .

Essential update: CDC reports most common sources of food-borne illnesses
Using data spanning the decade between 1998 and 2008, CDC investigators reported estimates for annual US food-borne illnesses, hospitalizations, and deaths attributable to each of 17 food categories.[1, 2] Among their findings: (1) leafy green vegetables were the most common cause of food poisoning (22%), primarily due to Norovirus species, followed by E coli O157; (2) poultry was the most common cause of death from food poisoning (19%), with Listeria and Salmonella species being the main infectious organisms; and (3) dairy items were the second most frequent causes of foodborne illnesses (14%) and deaths (10%), with the main factors being contamination by Norovirus from food handlers and improper pasteurization resulting in contamination with Campylobacter species.[1, 2]

Signs and symptoms
The symptoms of food poisoning vary in degree and combination. They may include the following: Abdominal pain: Most severe in inflammatory processes; painful abdominal muscle cramps suggest underlying electrolyte loss Vomiting: Major presenting symptom of S aureus, B cereus, or Norovirus[3] Diarrhea: Usually lasts less than 2 weeks Headache Fever: May be an invasive disease or an infection outside the GI tract Stool changes: Bloody or mucousy if invasion of intestinal or colonic mucosa; profuse rice-watery if cholera or a similar process Reactive arthritis: Seen with Salmonella, Shigella, Campylobacter, and Yersinia infections Bloating: May be due to giardiasis More serious cases of food poisoning can result in life-threatening neurologic, hepatic, and renal syndromes leading to permanent disability or death. See Clinical Presentation for more detail.

Examination of patients suspected of having food poisoning should focus on assessing the severity of dehydration. General findings may include the following:

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which can be achieved with either an oral rehydration solution or intravenous solutions in severely dehydrated individuals or those with intractable vomiting (eg. bismuth subsalicylate). antiperistaltics (eg. antibioticassociated diarrhea. especially in immunocompromised patients: Sigmoidoscopy/colonoscopy with biopsy EGD with duodenal aspirate and biopsy In patients with bloody diarrhea. tachycardia. and other lactose-containing foods during episodes of acute diarrhea. rifaximin): Selection of antibiotic depends on 2 of 7 27/07/2013 23:45 . shigellosis. Procedures Consider performing the following procedures when a stool examination is nondiagnostic.medscape. norfloxacin. sigmoidoscopy can be useful in diagnosing inflammatory bowel disease. and antibiotic treatment. loperamide) Antibiotics (eg. or obstructive symptoms or if the clinical picture suggests perforation. Management Most food-borne illnesses are mild and improve without any specific treatment. attapulgite.Food Poisoning Mild dehydration: A dry mouth. severe pain. TMX/SMP. hypotension Salmonellatyphi infection: Upper abdominal rose spot macules. ciprofloxacin. otitis media Always perform a rectal examination to (1) directly visualize the stool. decreased urine More severe volume depletion: Orthostasis. hepatosplenomegaly Yersinia infection: Erythema nodosum. See Workup for more detail. decreased axillary sweat. Patients should avoid milk. aluminum hydroxide). and (3) palpate the rectal mucosa for any lesions. opiate derivatives such as diphenoxylate with atropine. Testing The following routine laboratory tests may help to assess the patient’s inflammatory response and the degree of dehydration: CBC with differential Serum electrolyte assessment BUN and creatinine levels Other laboratory studies can be helpful in cases of food poisoning and include the following: Stool Gram staining and Loeffler methylene blue staining for WBCs: To help differentiate invasive disease from noninvasive disease Microscopic examination of the stool: To detect any ova and parasites Bacterial culture for enteric pathogens (eg.Campylobacter organisms): Mandatory when a stool sample shows positive results for WBCs or blood or if patients have fever or symptoms persisting for longer than 3-4 days Blood culture in notably febrile patients C difficile assay: To help rule out antibiotic-associated diarrhea in patients receiving antibiotics or in those with a history of recent antibiotic use Imaging studies Obtain flat and upright abdominal radiographs if the patient experiences bloating. Salmonella. as these individuals often develop an acquired disaccharidase deficiency due to washout of the brush-border enzymes. Shigella. doxycycline. and amebic dysentery. lactated Ringer solution).[4] Supportive care The main objective in managing patients with food poisoning is adequate rehydration and electrolyte supplementation. exudative pharyngitis Vibrio vulnificus or V alginolyticus infection: cellulitis. isotonic sodium chloride solution. Some patients have severe disease and require hospitalization. (2) test occult blood. aggressive hydration. Pharmacotherapy Medications that may be needed to treat patients with food poisoning include the following: Antidiarrheals: Absorbents (eg. dairy products. antisecretory agents (eg.

B cereus). leading to invasion and destruction. without invasion. Frequency United States Initially. Vibrio parahaemolyticus. Yersinia enterocolitica. Noninflammatory diarrhea is caused by the action of enterotoxins on the secretory mechanisms of the mucosa of the small intestine. aggressive hydration. staphylococci. vomiting is caused by a toxin acting on the central nervous system. Entamoeba histolytica. Most of the illnesses are mild and improve without any specific treatment. diarrhea. 7] However. hepatic. The US Centers for Disease Control and Prevention (CDC) estimates 1 in 6 Americans (48 million people) are affected by foodborne illness annually. Evidence of food as the source Pathophysiology The pathogenesis of diarrhea in food poisoning is classified broadly into either noninflammatory or inflammatory types. followed by systemic dissemination. in a minimum of 2 people 2. previously calledNorwalk virus). Bacillus cereus.[5] Staphylococcus organisms .com/article/175569-overview clinical setting and guided by microbiology and blood culture sensitivity results Prevention The best ways to prevent food poisoning caused by infectious agents are as follows: Practice strict personal hygiene Cook all foods adequately Avoid cross-contamination of raw and cooked foods Keep all foods at appropriate temperatures (ie. and headache. and adenovirus. arsenic. mercury. Inflammatory diarrhea is caused by the action of cytotoxin on the mucosa. or severe abdominal pain. toadstools] and heavy metals [eg. and sheets of leukocytes indicate colitis. The symptoms. and the availability of new surveillance data have changed the morbidity and mortality figures. The pathophysiological mechanisms that result in acute GIsymptoms produced by some of the noninfectious causes of food poisoning (naturally occurring substances [eg.medscape. and Salmonella and Shigella species. In some types of food poisoning (eg. viruses. mucoid and leukocytes are present. and renal syndromes leading to permanent disability or death. Examples include Vibrio cholerae.rotavirus. The diarrhea usually is bloody. Background Food poisoning is defined as an illness caused by the consumption of food or water contaminated with bacteria and/or their toxins. the organisms penetrate the mucosa and proliferate in the local lymphatic tissue. hot items: >140°F) See Treatment and Medication for more detail. The enterotoxins may be either preformed before ingestion or produced in the gut after ingestion. the identification of new food-borne diseases. Cryptosporidium. vomiting. The colon or the distal small bowel commonly is involved. Sometimes. enterohemorrhagic and enteroinvasive E coli.[4] A food-borne disease outbreak is defined by the following 2 criteria: 1. The 3 of 7 27/07/2013 23:45 . norovirus (genus Norovirus. profound dehydration may result. more serious cases can result in life-threatening neurologic.[6. and antibiotic treatment. Occasionally. Dehydration is less likely than with noninflammatory diarrhea because of smaller stool volumes. Patients are usually febrile and may appear toxic. Clostridium difficile.Food Poisoning http://emedicine. often GI. lead]) are not well known. Similar illness. food-borne diseases were estimated to be responsible for 6-8 million illnesses and as many as 9000 deaths each year. the change in food supply. varying in degree and combination. include abdominal pain. refrigerated items: < 40°F. Clostridium perfringens. Giardia lamblia. This leads to large volume watery stools in the absence of blood. The clinical syndrome of botulism results from the inhibition of acetylcholine release in nerve endings by the botulinum. Examples include Campylobacter jejuni. mushrooms. or with parasites. or chemicals. pus. Fecal leukocytes or a positive stool lactoferrin test indicates an inflammatory process. enterotoxic Escherichia coli. Some patients have severe disease and require hospitalization.

food-borne diseases appear to cause more illnesses but fewer deaths than previously estimated. and renal syndromes leading to permanent disability or death. nearly half (17) occurred in 2009 and 2010.[11] The CDC recognized the following outbreaks and sources in 2012:[8] E coli – Spinach and spring mix.[10] The most common pathogens are as follows:[8] Norovirus – 5.[13] This resulted in 102. habitation in a nursing home. travel. lack of exercise. and Y enterocolitica) caused 291.138 hospitalizations The pathogens most commonly associated with death are as follows: Salmonella – 378 deaths T gondii – 327 deaths Listeria monocytogenes – 255 deaths Norovirus – 149 deaths Campylobacter species – 76 deaths In March 2012.027. live poultry. diarrhea. Salmonella. Fish (17 outbreaks) were the most common source of implicated imported foodborne disease outbreaks.348 illnesses that were linked to imported food from 15 countries. Enterotoxigenic E coli is the most common isolate. E coli O157.686 deaths. decreased production of gastric acid and intestinal motility.000 people are hospitalized and 3. Shigella. Onset occurs 3 days to 2 weeks after arrival. raw clover sprouts at a national chain of restaurants Salmonella – Peanut butter.463 hospitalizations Toxoplasma gondii – 4. and prostration. 71. and Staphylococcus organisms. ricotta salata cheese. malnutrition. and migration and globalization of food production. headache. They may include abdominal pain.[8] The 31 known pathogens account for an estimated 9.336 hospitalizations Norovirus – 14. estimates suggest 128. More serious cases can result in life-threatening neurologic.961 hospitalizations.351 deaths. and marketing pose greater risk of cross-border transmission of infectious diseases and food-borne illness. and Salmonella. manufacturing. raw scraped ground tuna product.958 Campylobacter species – 845.Food Poisoning http://emedicine.663 hospitalizations Campylobacter species – 8. E coli 0157 . The CDC found that 5 bacterial enteric pathogens (Campylobacter. and 1. followed by spices (6 outbreaks including 5 from fresh or dried peppers). dry dog food. Nearly 50% of the outbreaks implicated food that was imported from regions not previously associated with outbreaks. Illness is self-limiting within 5 days. Unspecified agents account for 38.162 illnesses annually in children younger than 5 years. and excessive use of antibiotics. ground beef. The reasons for this increased susceptibility in elderly populations include age-associated decrease in immunity. Approximately 45% percent of the imported foods causing outbreaks came from Asia. Age Morbidity and mortality are higher in elderly individuals.731 cases Salmonella – 1. Elderly persons are more likely to die from infection with C perfringens. vomiting. hepatic. mangoes.561 C perfringens – 965. cantaloupe. the CDC reported a rise in foodborne disease outbreaks caused by imported food in 2009 and 2011.medscape.148 The most common pathogens responsible for hospitalizations are as follows:[8] Salmonella – 19. Within this 5-year period. Campylobacter. Mortality/Morbidity Symptoms vary in degree and combination.4 million cases.461. raw clover sprouts International Transnational trade.878 hospitalizations. Outbreaks reported to CDC’s Foodborne Disease Outbreak Surveillance System from 2005-2010 implicated 39 outbreaks and 2.4 million annual cases.000 die. and 1.746 doctor 4 of 7 27/07/2013 23:45 . small turtles.024 Staphylococcus aureus – 241.[12] A travel history should be obtained because traveler's diarrhea is the leading cause of travel-related illness.[9] Overall.428 hospitalizations E coli – 2.

Department of Internal Medicine. MD Director. Internal Medicine Residency Program. Department of Medicine. Digestive Health Center David Manuel.Food Poisoning http://emedicine. MBA. Department of Medicine. PLC Roberto M Gamarra. MSEd Residency Director. Michael H Piper. Contributor Information and Disclosures Author Roberto M Gamarra. American Medical Association. American Medical Association. Kovai Heart Foundation. Digestive Health Associates. American College of Physicians. MD Consulting Gastroenterologist. and 64 deaths. Division of Gastroenterology. Loyola University Health System. Wayne State University School of Medicine. Resident. American College of Physicians. Rates of illness remain higher in children.830 hospitalizations. American Society for Gastrointestinal Endoscopy. and Crohns and Colitis Foundation of America Disclosure: Nothing to disclose. Methodist Hospital. 7. FACP Senthil Nachimuthu is a member of the following medical societies: American College of Physicians Disclosure: Nothing to disclose. Associate Professor of Clinical Medicine. American Gastroenterological Association. Weill Cornell 5 of 7 27/07/2013 23:45 . MD Clinical Assistant Professor. visits. American College of Gastroenterology. and Michigan State Medical Society Disclosure: Nothing to disclose. Digestive Health Associates. Specialty Editor Board Jose A Perez Jr.medscape. American Gastroenterological Association. Department of Surgery. Vice Chair of Education. Coauthor(s) David Manuel. MD is a member of the following medical societies: American College of Gastroenterology. Priyankha Balasundaram. Consulting Staff. PLC Michael H Piper. MD. and Crohns and Colitis Foundation of America Disclosure: Nothing to disclose. MD is a member of the following medical societies: Alpha Omega Alpha. MD Affiliate Faculty. American College of Physicians. American Society of Gastrointestinal Endoscopy. India. Senthil Nachimuthu MD. MD is a member of the following medical societies: American College of Gastroenterology. Tulane University School of Medicine Disclosure: Nothing to disclose.

January 30. Mar 2012. 1998-2008. Chief Editor Julian Katz. Appleton & Lange: Stamford.medscape. Conn. Angulo FJ. MD. MSEd is a member of the following medical societies: American College of Physician Executives. 5. J Med Virol . [Medline]. and Society of General Internal Medicine Disclosure: Nothing to disclose. 2013. Hoekstra RM. 9. American College of Physicians. MD. Drexel University College of Medicine Julian Katz.17(1):7-15. and Physicians for Social Responsibility Disclosure: Nothing to disclose.medscape. United States. et al. MD is a member of the following medical societies: American College of Gastroenterology. hospitalizations. Francisco Talavera. Department of Internal Medicine. [Medline]. Most common foods for foodborne illness: CDC report. 2. Medscape Drug Reference Disclosure: Medscape Salary Employment Simmy Bank.61(9):1229-39. Accessed February 6. Jan 2011. Available at http://www. Bacillus and relatives in foodborne illness. Emerg Infect Dis. 10. Iturriza-Gomara M. 6. Xerry 3. 2013. Long Island Jewish Hospital. Alex J Mechaber. Complete genome sequence of Bacillus cereus bacteriophage BCP78. Foodborne illness in the elderly. Medicine for the Practicing Physician .19:3. [Full Text]. 2013 March. Hoekstra RM.17(1):16-22. Hoekstra RM. Griffin PM. [Full Text]. Professor. 6 of 7 27/07/2013 23:45 . Associate Professor of Medicine. American Gastroenterological Association. MBA. American Geriatrics Medical College Jose A Perez Jr. MMWR Morb Mortal Wkly Rep. FACP is a member of the following medical societies: Alpha Omega Alpha. [Medline]. PharmD. Medicine & Ethics. MD Clinical Professor of Medicine. 4. and Society of Hospital Medicine Disclosure: Nothing to disclose. Angulo FJ. [Full Text].112(3):417-29. Jan 2011. In: Hurst JW.86(1):637-8. American Society of Law. 2008. 8. American Trauma Society. et al.58(13):333-7. Doheny K. Division of Gastroenterology. American College of Physicians-American Society of Internal Medicine. Food borne diseases. Tauxe RV. ed. MD. Foodborne illness acquired in the United States-unspecified agents. Angulo FJ. Medscape Medical News. Son B. 4th ed. Ayers. Jul 2009. [Medline]. Association of American Medical Colleges. Logan NA. [Medline]. Gallimore CI. [Medline]. J Food Prot. Hughes JM. American Medical Association. Sep 1998. References 1. MD Chair. American Society for Gastrointestinal Endoscopy. [Full Text]. Smith JL. Emerg Infect Dis. PhD Adjunct Assistant Professor. Gray JJ. and deaths to food commodities by using outbreak data. Apr 10 2009. Scallan E. Shin H. Foodborne illness acquired in the United States--major pathogens. Preliminary FoodNet Data on the incidence of infection with pathogens transmitted commonly through food--10 States. Jan 2012. University of Nebraska Medical Center College of Pharmacy. [Medline]. 1996:344-7. University of Miami Miller School of Medicine Alex J Mechaber. Lee JH.Food Poisoning http://emedicine. J Virol. Albert Einstein College of Medicine Disclosure: Nothing to disclose. 7. Painter JA. J Appl Microbiol . Scallan E. American College of Physicians. Tracking the transmission routes of genogroup II noroviruses in suspected food-borne or environmental outbreaks of gastroenteritis through sequence analysis of the P2 domain. Emerg Infect Dis. FACP Senior Associate Dean for Undergraduate Medical Education. Attribution of foodborne illnesses. Ryu S.81(7):1298-304. Society of General Internal Medicine. Editor-in-Chief.

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