Traveler's Diarrhea Research Articles

A Cross-Sectional Cohort Study of Extended-Spectrum-Beta-Lactamase-Producing Enterobacterales in Patients with Traveler's Diarrhea.

Patients with traveler's diarrhea (TD) can acquire extended-spectrum-beta-lactamase (ESBL)-producing members of the Enterobacterales (EPE) during travel to areas of endemicity. The aim of the present study was to investigate the prevalence and characteristics of EPE carriage in travelers from southern Sweden who were sampled for bacterial diagnostics of TD compared to those of EPE carriage 10 years ago. Clinical samples sent for culture of common causes of bacterial enterocolitis, if the referral stated foreign travel, were included in the study. Antimicrobial susceptibility testing was done according to the EUCAST disk diffusion test method. EPE strains were subjected to whole-genome sequencing (WGS). Eighty-four of 303 patients carried a total of 92 ESBL-producing members of the Enterobacterales The overall prevalence of EPE in tested samples was thus 28%, compared to 24% 10 years earlier (P = 0.33). Among 86 strains available for WGS, 47 different sequence types (STs) were identified, and there were only 5 ST131 strains. Of the 79 Escherichia coli isolates, 76% carried at least one fim (type 1 fimbria) gene, 29% carried at least one pap (p-fimbriae) gene, and 43% were extraintestinal pathogenic E. coli (ExPEC) or uropathogenic E. coli (UPEC). Over half of the E. coli strains (57%) were intestinal pathogenic E. coli, most commonly enteroaggregative E. coli (EAEC) (33%), and enteroinvasive E. coli EIEC (22%). A relatively high proportion of patients with traveler's diarrhea carry EPE, but there was no significant increase compared to 10 years ago. Most E. coli strains were intestinal pathogenic strains. A comparatively high proportion of the strains were ExPEC/UPEC, many expressing the virulence genes pap and/or fim (This project was assigned ClinicalTrials.gov number NCT03866291.).

Travel Medicine

Abstract: Travel is an increasingly common aspect of modern life, and the practicing obstetrician–gynecologist needs a good understanding of the health- and safety-related issues it presents for patients. This monograph examines the environmental data that support individual risk assessment and provides guidance on how to eliminate or mitigate those risks, including recommendations for immunization and chemoprophylaxis for women traveling to areas with endemic infectious disease. Management approaches for travel-related diseases, such as traveler’s diarrhea, altitude sickness, and location-specific diseases, are reviewed as are special considerations for pregnant and breastfeeding women and women who are attempting pregnancy. Evaluation and management of the returned traveler also is addressed. The recommendations in this document cite resources available from the United States federal government; therefore, they are applicable to women seeking care in the United States.

A review of food poisoning caused by local food in Japan.

Increasingly popular worldwide, Japanese cuisine includes several raw preparations such as sashimi and sushi; however, limited information on food poisoning from Japanese local food is available in English literature. Without appropriate knowledge, physicians may underdiagnose traveler's diarrhea among people returning from Japan. To provide accurate information to primary care physicians worldwide, we conducted a narrative review on food poisoning research published in Japanese and English over the past four years, considering the frequency and clinical importance of various presentations.

Gastrointestinal symptoms and the acquisition of enteric pathogens in Hajj pilgrims: a 3-year prospective cohort study.

The acquisition of enteric pathogens and risk factors for Hajj-associated diarrhea in Hajj pilgrims is poorly documented. Pilgrims from Marseille participating in the Hajj in 2016-2018 underwent successive systematic rectal swabbing before and after their travel. Carriage of the main enteric pathogens was assessed by real-time PCR. Baseline demographics, adherence to individual preventive measures, gastrointestinal symptoms, and treatments were recorded. A total of 376 pilgrims were included. The median age was 62.0years. During the Hajj, 18.6% presented at least one gastrointestinal symptom, 13.8% had diarrhea, and 36.4% had acquired at least one enteric pathogen. Enteropathogenic Escherichia coli (EPEC) and Enteroaggregative E. coli (EAEC) were the pathogens most frequently acquired by pilgrims (17.6% and 14.4%, respectively). Being female was associated with increased frequency of gastrointestinal symptoms during the pilgrimage (aOR = 2.38, p = 0.004). Enterohemorrhagic Escherichia coli (EHEC) acquisition was associated with a four-fold higher risk of reporting at least one gastrointestinal symptom and diarrhea (aOR = 3.68 and p = 0.01 and aOR = 3.96 and p = 0.01, respectively). Pilgrims who suffered from diarrhea were more likely to wash their hands more often (aOR = 2.07, p = 0.03) and to be either overweight (aOR = 2.71, p = 0.03) or obese (aOR = 2.51, p = 0.05). Enteric bacteria such as E. coli that are frequently associated with traveler's diarrhea due to the consumption of contaminated food and drink were frequently found in pilgrims. Respecting strict measures regarding food and water quality during the Hajj and adherence to preventive measures such as good personal hygiene and environmental management will help reduce the burden of gastrointestinal infections at the event.

Prescribing Patterns of Antibiotics for the Self-Treatment of Travelers' Diarrhea in Global TravEpiNet, 2009-2018.

BackgroundInternational travelers are often prescribed antibiotics for self-treatment of travelers’ diarrhea (TD), but the benefits and risks of antibiotics are debated. We assessed the prescribing patterns of empiric antibiotics for TD in international travelers evaluated at Global TravEpiNet (GTEN) sites (2009–2018). MethodsWe performed a prospective, multisite cross-sectional study regarding antibiotic prescriptions for the self-treatment of TD at 31 GTEN sites providing pretravel consultations to adult international travelers. We described traveler demographics, itineraries, and antibiotic(s) prescribed. We used multivariable logistic regressions to assess the association of year of consultation with antibiotic prescribing (yes/no) and class (fluoroquinolones vs azithromycin). We performed interrupted time-series analyses to examine differences in prescribing before and after the Food and Drug Administration (FDA) warning on fluoroquinolones (July 2016). ResultsAntibiotics were not prescribed in 23 096 (22.2%) of 103 843 eligible pretravel GTEN consultations; azithromycin and fluoroquinolones were most frequently prescribed. Antibiotic prescribing declined significantly each year between 2009 and 2018 (odds ratio [OR], 0.84; 95% CI, 0.79–0.89), as did fluoroquinolone prescribing, relative to azithromycin (OR, 0.77; 95% CI, 0.73–0.82). The rate of decline in fluoroquinolone prescribing was significantly greater after the FDA fluoroquinolone warning (15.3%/year) than before (1.1%/year; P < .001). ConclusionsEmpiric antibiotics for TD were prescribed in >75% of pretravel GTEN consultations, but antibiotic prescribing declined steadily between 2009 and 2018. Fluoroquinolones were less frequently prescribed than azithromycin, especially after the 2016 FDA fluoroquinolone warning. Emphasis on the risks of antibiotics may influence antibiotic prescribing by providers for empiric treatment of TD.

Clinical aspects of heat-labile and heat-stable toxin-producing enterotoxigenic Escherichia coli: A prospective study among Finnish travellers

BackgroundEnterotoxigenic Escherichia coli (ETEC) is a major pathogen causing travellers’ diarrhoea (TD) among visitors to low- and middle-income countries (LMIC). Scant data are available on rates of travel-acquired ETEC producing heat-labile (LT) and/or heat-stable (ST) toxin or its subtypes, STh (human) and STp (porcine) in various geographic regions, and on clinical pictures associated with each toxin. MethodsUsing qPCR, we analysed LT, STh, and STp in stools positive for ETEC in a prospective study among 103 Finnish travellers visiting LMIC. They filled in questionnaires and provided stool samples before and after travel. We scrutinized geographic distribution of LT, STh, and STp ETEC findings, and association between these different ETEC subtypes and moderate/severe TD. ResultsAmong the 103 stool samples positive for ETEC toxins, the rate for LT was 76%, for STh 26%, and STp 41%. The rate for LT-only was 44%, for STh-only 6%, STp-only 16%, LT + STh 10%, LT + STp 15%, STh + STp 3%, and LT + STh + STp 8%. Findings varied by destination; the rates of LT, STh, and STp were 79%, 21%, and 57%, respectively, in Southern Asia (n = 14); 85%, 10%, and 20% in South-eastern Asia (n = 20); 84%, 13%, and 29% in Eastern Africa (n = 31); and 56%, 50%, and 63% in Western Africa (n = 32), respectively. Of travellers positive for LT, STh, and STp, 83%, 100%, and 88%, encountered TD; 35%, 55%, and 41% reported moderate/severe TD. STh was associated with moderate/severe TD. ConclusionsToxin findings varied by destination; multiple toxins were commonly detected. Moderate/severe TD was reported most frequently by subjects with STh-ETEC.

Spectrum of enteropathogens in cases of traveler's diarrhea that were detected using the FilmArray GI panel: New epidemiology in Japan

IntroductionTraveler's diarrhea (TD) is the most common illness among people traveling from resource-rich regions to resource-limited regions, although the precise microbial etiology is unclear in many cases. MethodsStool specimens were prospectively collected from 106 consecutive patients with TD and 16 healthy controls without TD, and were tested using both the FilmArray gastrointestinal panel (BioFire Diagnostics) and conventional stool cultures. ResultsThe 106 patients had traveled to Southeast Asia (55 cases), South Asia (22 cases), Africa (11 cases), and East Asia (7 cases). Among the 106 specimens, 95 specimens (89.6%) were positive for pathogens during the FilmArray testing. The FilmArray testing also identified multiple pathogens in 75.8% of the specimens from positive cases. Conventional stool cultures only detected pathogens in 23.6% of the specimens. ConclusionThe FilmArray gastrointestinal panel significantly improved the detection of enteropathogens and allowed for a rapid assessment of the TD's etiology. In addition, conventional stool cultures are likely to underestimate co-infections with multiple infectious pathogens.

Doxycycline Malaria Prophylaxis Impact on Risk of Travelers' Diarrhea among International Travelers.

.International travelers are frequently at risk for travelers’ diarrhea (TD) and malaria. Doxycycline was one of the earliest antibiotics shown to have efficacy in TD prevention. With increasing resistance and recommendations against antibiotic chemoprophylaxis, doxycycline fell out of use. We evaluated TD incidence and risk factors in a prospective cohort of travelers, specifically in regard to malaria prophylaxis. Travelers’ diarrhea was defined as ≥ 3 loose stools in 24 hours or two loose stools in 24 hours associated with other gastrointestinal symptoms. The Poisson regression model with robust error variance was used to estimate the RR of TD. Three thousand two hundred twenty-seven trips were enrolled: 62.1% of participants were male, with a median age of 39 years (interquartile range [IQR] 27,59) and a median travel duration of 19 days (IQR 12,49); 17.4% developed TD; 32% traveled to Africa, 40% to Asia, and 27% to the Caribbean and Latin America; and 20% took doxycycline for malaria chemoprophylaxis, 50% took other antimalarials, and 30% took none. Decreased RR of TD was associated with doxycycline (RR 0.62 [0.47–0.82], P < 0.01) and military travel (RR 0.57 [0.47–0.70], P < 0.01). Increased risk of TD was associated with female gender (RR 1.28 [1.09–1.50], P < 0.01), hotel accommodations (RR 1.30 [1.10–1.53], P < 0.01), travel to tropical South America (RR 1.34 [1.09–1.64], P < 0.01), and duration of travel (RR 1.00 [1.00–1.01], P < 0.01). The use of doxycycline for malaria prophylaxis is associated with lower TD risk, suggesting increasing bacterial enteropathogen susceptibility similar to previous observations. Doxycycline selection for antimalarial chemoprophylaxis may provide additional traveler benefit in infection prevention.

Epidemiology and associated microbiota changes in deployed military personnel at high risk of traveler's diarrhea.

Travelers' diarrhea (TD) is the most prevalent illness encountered by deployed military personnel and has a major impact on military operations, from reduced job performance to lost duty days. Frequently, the etiology of TD is unknown and, with underreporting of cases, it is difficult to accurately assess its impact. An increasing number of ailments include an altered or aberrant gut microbiome. To better understand the relationships between long-term deployments and TD, we studied military personnel during two nine-month deployment cycles in 2015-2016 to Honduras. To collect data on the prevalence of diarrhea and impact on duty, a total of 1173 personnel completed questionnaires at the end of their deployment. 56.7% reported reduced performance and 21.1% reported lost duty days. We conducted a passive surveillance study of all cases of diarrhea reporting to the medical unit with 152 total cases and a similar pattern of etiology. Enteroaggregative E. coli (EAEC, 52/152), enterotoxigenic E. coli (ETEC, 50/152), and enteropathogenic E. coli (EPEC, 35/152) were the most prevalent pathogens detected. An active longitudinal surveillance of 67 subjects also identified diarrheagenic E. coli as the primary etiology (7/16 EPEC, 7/16 EAEC, and 6/16 ETEC). Eleven subjects were recruited into a nested longitudinal substudy to examine gut microbiome changes associated with deployment. A 16S rRNA amplicon survey of fecal samples showed differentially abundant baseline taxa for subjects who contracted TD versus those who did not, as well as detection of taxa positively associated with self-reported gastrointestinal distress. Disrupted microbiota was also qualitatively observable for weeks preceding and following the incidents of TD. These findings illustrate the complex etiology of diarrhea amongst military personnel in deployed settings and its impacts on job performance. Potential factors of resistance or susceptibility can provide a foundation for future clinical trials to evaluate prevention and treatment strategies.

Antibiotic Resistance Pattern and Detection of Enterotoxigenic and Enteroaggregative Strain of Escherichia coli among Foreign Tourist with Traveler Diarrhea in Bali using Uniplex Polymerase Chain Reaction

BACKGROUND: As one of the major tourist destinations in Southeast Asia, Bali received millions of foreign tourists each year. Diarrhea consistently placed as the most often experienced health problem among travelers. Traveler diarrhea has various etiologies. The most common was Escherichia coli. The existence of several types of E. coli that are resistant to several antibiotics causes the selection of antibiotics is crucial.&#x0D; AIM: This preliminary study aims to understand the pattern of antibiotics sensitivity and to detect the presence of enterotoxigenic and enteroaggregative strains of E. coli from fecal samples of foreign tourists with traveler’s diarrhea in Denpasar, Bali.&#x0D; METHODS: A culture examination was carried out to obtain E. coli bacterial colonies. Disk diffusion Kirby–Bauer was carried out for antibiotic sensitivity testing. The confirmed colonies were tested against several common antibiotics, including the recommended first line (ciprofloxacin and azithromycin). Uniplex polymerase chain reaction (PCR) using specific primers conducted to detect the enterotoxigenic E. coli (ETEC) (elt and estA2-4) and enteroaggregative E. coli (EAEC) (CVD432) strains.&#x0D; RESULTS: Among 48 stool culture, 14 (29.2%) were identified as E. coli colonies. All samples were still sensitive to the antibiotics meropenem, ceftazidime, and cefixime. Despite majority of the samples (78.6%) still sensitive to ciprofloxacin, large proportion of the samples have developed resistance against the other commonly used antibiotics, doxycycline (70.4%) and azithromycin (57.1%). PCR showed that 3 (21.4%) samples shown positive for CVD432 gene, 2 (14.3%) samples positive for the elt gene, and all negative for the estA2-4 gene.&#x0D; CONCLUSION: An only small proportion of E. coli was EAEC or ETEC strain. Although most E. coli still sensitive to beta-lactam antibiotics, a significant proportion had shown resistance against the commonly recommended first-line antibiotics.

Travel preparation and health risks in Dutch and Belgian medical students during an elective in low- or middle-income countries: A prospective self-reporting cohort study

BackgroundMedical schools offer students the opportunity to perform international electives. This study aimed to assess health risks among medical students, to tailor institutional guidelines. MethodsMulticenter study at Dutch and Belgian universities, among medical students who visited low- or middle-income countries. Students completed four questionnaires: once before the elective and two weeks, three- and six months after return. ResultsData was complete for 479 students (follow-up rate 84%). Most traveled to Surinam (29%) and South-Africa (14%). Half of the students encountered difficulties in adapting to local culture. Almost 40% visited malaria endemic countries. Nearly all (87%) used chemoprophylaxis as prescribed. Definite needle-stick or splash injuries were reported by 7%. All were dealt with adequately in accordance with national guidelines. However, less than half of 24 possible incidents were handled adequately. Two-and-a-half percent had unprotected sex with a new partner. The incidence of travelers’ diarrhea (TD) was 46%. In those with TD, the incidence of post-travel new-onset abdominal complaints was 3%. Three percent were involved in a minor traffic accident, 18% were injured during leisure activities, 5% were threatened or experienced physical violence. Only half of the students visiting a highly endemic country were screened for tuberculosis post-travel. For schistosomiasis this was 6%. ConclusionsStudents abroad are exposed to medical and non-medical challenges, which should be addressed during pre-travel counseling. Contact details of a professional back home should be provided, so students can confer in case of problems while abroad. Lastly, we recommend a centrally organized post-travel health check.

Genetic and Virulence Profiles of Enteroaggregative Escherichia coli (EAEC) Isolated From Deployed Military Personnel (DMP) With Travelers' Diarrhea.

To discern if there was a particular genotype associated with clinical enteroaggregative Escherichia coli (EAEC) strains isolated from deployed military personnel (DMP) with travelers' diarrhea (TD), we characterized a collection of EAEC from DMP deployed to Afghanistan, Djibouti, Kenya, or Honduras. Although we did not identify a specific EAEC genotype associated with TD in DMP, we found that EAEC isolated at the first clinic visit were more likely to encode the dispersin gene aap than EAEC collected at follow-up visits. A majority of the EAEC isolates were typical EAEC that adhered to HEp-2 cells, formed biofilms, and harbored genes for aggregative adherence fimbriae (AAF), AggR, and serine protease autotransporters of Enterobacteriaceae (SPATEs). A separate subset of the EAEC had aggR and genes for SPATEs but encoded a gene highly homologous to that for CS22, a fimbriae more commonly found in enterotoxigenic E. coli. None of these CS22-encoding EAEC formed biofilms in vitro or adhered to HEp-2 cells. Whole genome sequence and single nucleotide polymorphism analyses demonstrated that most of the strains were genetically diverse, but that a few were closely related. Isolation of these related strains occurred within days to more than a year apart, a finding that suggests a persistent source and genomic stability. In an ampicillin-treated mouse model we found that an agg4A+ aar- isolate formed a biofilm in the intestine and caused reduced weight gain in mice, whereas a strain that did not form an in vivo biofilm caused no morbidity. Our diverse strain collection from DMP displays the heterogeneity of EAEC strains isolated from human patients, and our mouse model of infection indicated the genotype agg4A+ aar– and/or capacity to form biofilm in vivo may correlate to disease severity.

Treatment of traveler's diarrhea - clinical review

Travelers’ diarrhea is defined as the passage of three or more unformed stools per 24 hours plus at least one additional symptom such as nausea, vomiting, abdominal cramps, fever, blood/mucus in the stools, or fecal urgency that develop while abroad or within 14 days of returning from any resource-limited destinations.The aim of this study was to show the methods of treatment of traveler's diarrhea. Our study material consisted of publications, which were found in PubMed, ResearchGate and Google Scholar databases. In order to find the proper publications, the search has been conducted with the use of a combination of key words like: '' traveler's diarrhea,'', ''travel'', ''diarrhea'', ''antibiotic". The first step was to find proper publications from the last 30 years .The second step was to carry out an overview of the found publications.Major goals of treatment of the traveler's diarrhea are: to maintain optimal hydration level, to reduce the severity and duration of diarrhea and to eradicate pathogenic agents responsible for causing this disease. The choice of the best possible method of tretament of traveler's diarrhea depends on the patient's general condition, his medical history, severity and duration of diarrhea and the pathogenic agent that causes this disease.

Incidence of Travelers’ Diarrhea among Adult Foreign Travelers in Thailand: A Prospective Study

Travelers' diarrhea (TD) is common among foreign travelers to Thailand. We performed a prospective cohort study to determine the TD incidence among foreign adult travelers to Thailand. We retrieved baseline demographic data, travel plans, and health history on enrolling individuals and collected follow-up questionnaires on days 7, 14, and 28 from the day of arrival. We analyzed data from 349 eligible participants. The mean participants' age was 32.3 years; 55.4% were men. Most of the participants had visited a travel clinic for vaccinations and counseling after arrival in Thailand. The cumulative incidences of the participants developing TD were 14.0% (49/349), 23.5% (82/349), and 33.0% (115/349) at 7, 14, and 28 days, respectively. The median time to develop TD was 9 days (interquartile range 5-18 days) post-arrival. Of 115 participants with TD, 64.3% (74/115) consulted a physician, 1.7% (2/115) were hospitalized, and 11.3% (13/115) had to change their travel plans. We identified young age, eating street food, and not routinely washing hands after using a toilet as risk factors significantly associated with the incidence of TD using the log-rank test in our survival analysis. Up to one-third of foreign travelers developed diarrhea during the first month, and some cases were severe. Although no highly effective TD prevention method exists, the practice of good personal hygiene and avoidance of food and drinks derived from unsanitary sources are still recommended to reduce the risk of travelers' TD.

Risk factors for different intestinal pathogens among patients with traveler's diarrhea: A retrospective analysis at a German travel clinic (2009–2017)

BackgroundTravelers’ diarrhea (TD) is the most common illness experienced by travelers to developing regions of the world and may be caused by bacterial, parasitic or viral pathogens. The available diagnostic tests include stool microscopy for parasitic infections, culture-dependent methods for bacterial infections and molecular methods for bacterial, parasitic and viral infections. MethodWe retrospectively evaluated demographic, clinical and microbiological data of patients presenting with TD at our travel clinic between 2009 and 2017. ResultsAmong 676 patients with TD included in our study, at least one etiologic agent was found in 21% (n = 145) of cases. In total, 195 enteropathogens were detected of which 110 were bacteria, 70 protozoa and 15 helminths. Bacterial infections were significantly more common when symptoms were present less than 14 days and travel duration did not exceed 29 days. Protozoa and helminths were predominantly detected in patients with longer lasting complaints. After stool culture was replaced by a multiplex-PCR gastrointestinal pathogen panel (GPP) at our center, significantly more intestinal bacterial pathogens were detected. ConclusionsOur results support an individualized approach in the diagnostic workup of patients with TD taking host and travel characteristics into account to avoid unnecessary diagnostic testing. Molecular culture-independent diagnostic stool tests provide better coverage of the variety of etiological agents than traditional stool culture and have the benefit of rapid detection. However, the high sensitivity bears challenges differentiating colonization from infection.

Aetiology of traveller's diarrhea: A nested case-control study

BackgroundTraveller's diarrhea (TD) is the leading cause of morbidity among travelers. Recently, molecular methods have been developed to detect the causative pathogens of TD. The aim of this study was to test a multiplex-PCR approach in patients with TD and asymptomatic controls. MethodsIn total, 91 travelers (61 TD cases, 30 asymptomatic controls) prospectively collected stool samples during travel and documented gastrointestinal symptoms. Samples were analyzed using the BioFire® FilmArray® Gastrointestinal Panel, which covers 13 enteric bacteria (e.g. diarrheagenic Escherichia coli), 4 protozoan parasites and 5 viruses. ResultsTD cases had more likely a positive test (46/61, 75%) compared to controls (17/30, 57%, p = 0.07). The most common enteric pathogens were enteroaggregative E. coli (36/91, 40%), followed by enterotoxigenic E. coli (31/91, 34%) and enteropathogenic E. coli (EPEC, 29/91, 32%). The only pathogens significantly associated with TD were EPEC (p = 0.01) and ETEC (p = 0.047). Protozoan parasites were not detected. ConclusionOur results challenge the widespread use of multiplex-approaches covering numerous enteric pathogens in the diagnostic workup of TD because only few (i.e. diarrheagenic E. coli) were related to symptoms of TD.

Travel, Diarrhea, Antibiotics, Antimicrobial Resistance and Practice Guidelines—a Holistic Approach to a Health Conundrum

Given the recent interest in the interface between travelers’ diarrhea (TD) management guidelines and antimicrobial resistance from both the patient and population perspectives, we have undertaken a review of the evidence with an aim towards practical and pragmatic recommendations. Antimicrobial resistance continues to be an existential threat. Therefore, an update is needed on the pathogens that cause TD, the role of antibiotics, the potential changes in microbiome and acquisiton of multi-drug resistant (MDR) bacteria, and lastly the impact of MDR acquisition of the traveler on individual, community, and global health through a holistic framework. Important research gaps and opportunities in this area are identified, as well as practical guidance for the travel medicine community offered.

Health risk of travel for chronic kidney disease patients.

The number of people with chronic kidney disease (CKD) has increased and so has their demand for travel. However, the health risk posed by travel in these patients is unclear. Few reports document the travel risk in CKD and dialysis patients. The aim of this study is to summarize the existing evidence of the influence of travel on risks in CKD patients. We aim to describe the association between the impact of travel risks and patients with CKD. A detailed review of recent literature was performed by reviewing PubMed, Google Scholar, and Ichushi Web from the Japan Medical s Society. Screened involved the following keywords: “traveler's thrombosis,” “venous thromboembolism,” “deep vein thrombosis,” “altitude sickness,” “traveler's diarrhea,” “jet lag syndrome,” “melatonin,” with “chronic kidney disease” only, or/and “dialysis.” We present a narrative review summary of the literature from these screenings. The increased prevalence of thrombosis among travelers with CKD is related to a decrease in the estimated glomerular filtration rate and an increase in urine protein levels. CKD patients who remain at high altitudes are at an increased risk for progression of CKD, altitude sickness, and pulmonary edema. Traveler's diarrhea can become increasingly serious in patients with CKD because of decreased immunity. Microbial substitution colitis is also common in CKD patients. Moreover, time differences and disturbances in the circadian rhythm increase cardiovascular disease events for CKD patients. The existing literature shows that travel-related conditions pose an increased risk for patients with CKD.

Epidemiology of Enterotoxigenic Escherichia coli infection in Minnesota, 2016-2017.

Enterotoxigenic Escherichia coli (ETEC) is a well-established cause of traveller's diarrhoea and occasional domestic foodborne illness outbreaks in the USA. Although ETEC are not detected by conventional stool culture methods used in clinical laboratories, syndromic culture-independent diagnostic tests (CIDTs) capable of detecting ETEC have become increasingly prevalent in the last decade. This study describes the epidemiology of ETEC infections reported to the Minnesota Department of Health (MDH) during 2016-2017. ETEC-positive stool specimens were submitted to MDH to confirm the presence of ETEC DNA by polymerase chain reaction (PCR). Cases were interviewed to ascertain illness and exposures. Contemporaneous Salmonella cases were used as a comparison group in a case-case comparison analysis of risk factors. Of 222 ETEC-positive specimens received by MDH, 108 (49%) were concordant by PCR. ETEC was the sixth most frequently reported bacterial enteric pathogen among a subset of CIDT-positive specimens. Sixty-nine (64%) laboratory-confirmed cases had an additional pathogen codetected with ETEC, including enteroaggregative E. coli (n = 40) and enteropathogenic E. coli (n = 39). Although travel is a risk factor for ETEC infection, only 43% of cases travelled internationally, providing evidence for ETEC as an underestimated source of domestically acquired enteric illness in the USA.

Gastrointestinal infections in returned travelers.

Gastrointestinal infections are one of the most frequent medical conditions diagnosed in patients who travel to tropical or subtropical destinations. The most common disorder occurring in up to 60% travelling people is travelers' diarrhea (TD). The illness is defined as a minimum of three loose stools within 24 hours; in most cases TD is caused by the enterotoxigenic Escherichia coli. Its symptoms usually persist for 4-5 days and resolve spontaneously or on self-administered empirical antimicrobial therapy, but in case of an invasive infection, it is necessary to seek medical care. As most tourists travel for 1-2 weeks, the disease often persists or develops upon return; therefore, it is important to raise awareness of TD's clinical features and treatment options among physicians from travelers' home countries unaccustomed to this health problem. Another issue, which is gaining more and more importance in recent years, is post-infectious irritable bowel syndrome, a chronic disturbance affecting up to 17% of patients, who have had travelers' diarrhea. This review aims to promote prophylaxis of gastrointestinal disorders and to extend knowledge about their after-effects in returned travelers.