Food-borne Diarrheal Infection

Aka: Food-borne Diarrheal Infection, Foodborne Illness, Food-Borne Disease, Foodborne Disease, Food Poisoning

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II. Epidemiology

  1. Incidence increasing in United States
    1. Cases per year: 48 million
    2. Hospitalizations: 128,000
    3. Diarrheal related deaths per year: 3000
    4. Medical and associated costs per year: $4-14 billion
    5. Most cases are not seen by medical care
  2. Expanded fast food industry in part responsible
    1. Large scale food production affects many people
    2. More virulent organisms may be evolving
    3. Highly processed foods (including ground meats which distribute contamination throughout food)

III. Risk Factors

  1. Increased intake of raw and partially processed food
  2. Special backcountry camping risks (no refrigeration)
  3. Improperly stored, cooked or reheated foods
  4. Frequent sources of foodborne Diarrhea outbreaks
    1. Chicken (Most common)
    2. Mexican Food
    3. Chinese Food
    4. Fin fish
    5. Shellfish
    6. Beef (least common)

IV. Causes: Food Pathogens

  1. Most common Food Pathogens in U.S.
    1. Norovirus or Norwalk Virus (onset 12-48 hours)
      1. See Waterborne Illness
      2. Incidence (U.S.): 5.5 Million cases with 15,000 hospitalizations and 150 deaths (0.0027% mortality) per year
      3. Worldwide, Norovirus is responsivble for 200,000 deaths per year in developing countries
      4. Contaminated raw produce
      5. Shellfish from contaminated water
      6. Infected food preparer of uncooked foods
    2. Non-typhoid Salmonella (onset 6-48 hours)
      1. Incidence (U.S.): 1 Million cases with 19,000 hospitalizations and 380 deaths (0.38% mortality) per year
      2. Raw poultry
      3. Shellfish
      4. Eggs
      5. Cheese
      6. Contaminated raw produce
      7. Unpasteurized milk or juice
    3. Clostridium perfringens via in-vivo toxin production (onset 6-16 hours, self-resolves by 24 hours)
      1. Incidence (U.S.): 970,000 cases with 440 hospitalizations and 26 deaths (0.0027% mortality) per year
      2. Associated with fever and Headache
      3. Pre-cooked meats
      4. Dried foods
      5. Meats or gravy
      6. Poultry
    4. Campylobacter jejuni (onset 2-5 days)
      1. Incidence (U.S.): 850,000 cases with 8500 hospitalizations and 76 deaths (0.0089% mortality) per year
      2. Raw chicken (66% infected)
      3. Unpasteurized milk
    5. Staphylococcus aureus via pre-formed Enterotoxin (onset 1-6 hours)
      1. Incidence (U.S.): 240,000 cases with 1100 hospitalizations and 6 deaths (0.0025% mortality) per year
      2. Resolves in 1-2 days without treatment
      3. Nausea, Vomiting and abdominal cramping are most common
        1. Diarrhea is less prominent and may persist for 3 days after onset)
      4. Eggs
      5. Mayonnaise
      6. Cold meats
      7. Pork
      8. Chicken
      9. Beef
      10. Seafood
      11. Salads
      12. Cream-filled desserts
    6. Shigella (Shigellosis, onset 4-7 days)
      1. Similar Waterborne Illness sources as Norovirus (see above)
      2. Incidence (U.S.): 130,000 cases with 1500 hospitalizations and 10 deaths (0.0077% mortality) per year
    7. Enterotoxigenic Escherichia coli (Traveler's Diarrhea, rapid onset 1-3 days)
      1. Food or water contaminated by human feces
      2. Incidence (U.S.): 110,000 cases with 270 hospitalizations and 1 death (rare mortality) per year
  2. Less Common Food Pathogens in U.S.
    1. Yersinia enterocolitica
      1. Incidence (U.S.): 98,000 cases with 530 hospitalizations and 29 deaths (0.03% mortality) per year
      2. Waterborne Illness
    2. Toxoplasma gondii (Toxoplasmosis)
      1. Incidence (U.S.): 87,000 cases with 4400 hospitalizations and 330 deaths (0.38% mortality) per year
      2. Raw or under-cooked meat (pork, mutton, wild game)
      3. Ingested items contaminated with cat feces
    3. Enterohemorrhagic E. coli (E. coli 0157:H7, onset 1-8 days)
      1. Incidence (U.S.): 63,000 cases with 2100 hospitalizations and 20 deaths (0.032% mortality) per year
      2. Hamburger and other red meat (undercooked)
      3. Contaminated raw produce (e.g. Seed sprouts)
      4. Unpasterurized juice or milk
    4. Bacillus Cereus (onset 10-16 hours)
      1. Incidence (U.S.): 63,000 cases with 20 hospitalizations and 0 deaths per year
      2. Causes 2 syndromes
        1. Toxin-mediated with acute Vomiting (similar to staph aureus) esp. after fried rice ingestion
        2. Diarrheal illness similar to Clostridium perfringens
      3. Hamburger (45-63% infected)
      4. Raw rice (100% infected)
      5. Fried rice
      6. Meats, stews and gravy
      7. Vanilla sauce
    5. Vibrio parahaemolyticus, V. fluvialis, V. mimicus and non-toxigenic V. Cholerae (4-96 hours)
      1. Incidence (U.S.): 35,000 cases with 100 hospitalizations and 4 deaths (0.011 mortality) per year
      2. Shellfish or raw seafood
      3. Typically only severe in Immunocompromised patients
        1. Vibrio vulnificus is more significant (see above)
  3. Rare Food Pathogens in U.S.
    1. Listeria monocytogenes (onset 9-48 hours, invasive disease delayed for weeks)
      1. Meats (50-100% infected)
      2. Deli Meats
      3. Uncooked hot dogs
      4. Cantaloupe
      5. Unpasteurized milk and soft cheeses
    2. Vibrio vulnificus (onset 1-7 days)
      1. Raw oysters
    3. Clostridium botulinum (Botulism, onset 12-72 hours)
      1. Fermented fish
      2. Poor canning technique (especially home canned vegetables)
      3. Potatoes baked in aluminum foil
    4. Hepatitis A (onset 15-50 days)
      1. Similar Waterborne Illness sources as Norovirus (see above)
    5. Enterovirus
      1. Shellfish (47% infected)
    6. Cyclospora cayetanensis (Cyclosporiasis, onset 7-14 days)
      1. Contaminated raw produce (lettuce, basil, imported berries)
    7. Aeromonas Hydrophila
      1. Poultry (95% infected)
      2. Fish (95% infected)
      3. Red Meat (95% infected)
      4. Produce: lettuce, celery (95% infected)

V. Causes: Common food sources of Foodborne Illness

  1. See Waterborne Illness
  2. Improperly stored, cooked or reheated foods (e.g. buffets, picnics)
    1. Staphylococcus aureus
    2. Bacillus Cereus
    3. Shiga-toxin producing E. coli (e.g. E. coli 0157:H7, Enterohemorrhagic E. coli)
  3. Unpasteurized dairy products
    1. Salmonella
    2. Campylobacter
    3. Shiga-toxin producing E. coli (e.g. E. coli 0157:H7, Enterohemorrhagic E. coli)
    4. Listeria monocytogenes
    5. Brucella
    6. Yersinia enterocolitica
  4. Raw Beef or Pork
    1. Staphylococcus aureus
    2. Bacillus Cereus
    3. Shiga-toxin producing E. coli (e.g. E. coli 0157:H7, Enterohemorrhagic E. coli)
    4. Clostridium perfringens
    5. Listeria monocytogenes
    6. Toxoplasmosis
    7. Brucella
  5. Pigs or Pork
    1. Yersinia
    2. Trichinella
  6. Poultry
    1. Nontyphoidal Salmonella
    2. Campylobacter jejuni
    3. Listeria monocytogenes
  7. Reptile Exposure
    1. Salmonella
  8. Cat Exposure
    1. Toxoplasmosis
  9. Fish or seafood
    1. Shellfish
      1. Vibrio parahaemolyticus (or Vibrio haemolyticus)
      2. Vibrio Cholera
    2. Raw Fish
      1. Salmonella
      2. Hepatitis A
      3. Aeromonas Hydrophila
    3. Raw Oysters
      1. Vibrio vulnificus (Similar to Vibrio Cellulitis)
    4. Fish with pre-formed toxins
      1. Ciguatera Poisoning (Reef fish ingestion such as grouper, snapper, barracuda)
      2. Scombroid Poisoning (Tuna, Mahi-mahi, Mackeral, Swordfish)
      3. Tetrodotoxin (pufferfish, porcupinefish, ocean sunfish, or triggerfish)
  10. Wild rabbit
    1. Tularemia

VI. Symptoms: Gastrointestinal by Cause

  1. Acute symptoms in multiple people with same food exposure (Preformed toxins)
    1. Symptom onset within 6 hours (presents with Vomiting)
      1. Staphylococcus aureus (often from cold mayonnaise-based salads)
      2. Bacillus Cereus (meats, rice)
    2. Symptom onset within 8-16 hours (presents with Diarrhea)
      1. Clostridium perfringens (Cooked meats)
  2. Watery Diarrhea (noninvasive osmotic dysfunction)
    1. Enterotoxigenic Escherichia coli
    2. Vibrio Cholerae
    3. Cryptosporidium
    4. Cyclospora
    5. Enteric Viruses
  3. Invasive or Inflammatory Diarrhea (Acute Abdominal Pain, fever, tenesmus, bloody Diarrhea)
    1. Nontyphoidal Salmonella
    2. Yersinia enterocolitica
    3. Shigella
    4. Vibrio parahaemolyticus (or Vibrio haemolyticus)
    5. Campylobacter jejuni
    6. Shiga-toxin producing E. coli (e.g. E. coli 0157:H7, Enterohemorrhagic E. coli)
    7. Clostridium difficile
  4. Bloody Diarrhea
    1. See Invasive or Inflammatory Diarrhea causes above
    2. Salmonella
    3. Shigella
    4. Shiga-toxin producing E. coli (e.g. E. coli 0157:H7, Enterohemorrhagic E. coli)
    5. Campylobacter
    6. Vibrio parahaemolyticus
    7. Yersinia
    8. Entamoeba histolytica
  5. Foul smelling Diarrhea
    1. Clostridium difficile
    2. Giardia lamblia
  6. Vomiting
    1. Preformed toxins (onset within 6-12 hours) typically cause significant non-bilious, non-bloody Emesis
    2. Bacillus cereus
    3. Clostridium botulinum
    4. Norwalk Virus
    5. Staphylococcus aureus
    6. Vibrio Cholerae (01)
    7. Vibrio parahaemolyticus

VII. Symptoms: Systemic by Cause

  1. Fever
    1. Campylobacter jejuni
    2. Norwalk Virus
    3. Salmonella
    4. Shigella
    5. Vibrio Cholerae (non-01)
    6. Vibrio parahaemolyticus
  2. Neurologic Symptoms
    1. Amatoxin Mushrooms (encephalopathy)
    2. Campylobacter (Guillain-Barre Syndrome)
    3. Ciguatera Poisoning (perioral Paresthesias, cold Allodynia)
    4. Clostridium botulinum (Diplopia, descending paralysis)
    5. Listeria monocytogenes (Nuchal Rigidity, confusion, myalgias)
    6. Muscarine Mushrooms (Cholinergic Toxicity)
    7. Psilocybin mushrooms (Hallucinations)
    8. Tetrodotoxin such as pufferfish, porcupinefish, ocean sunfish, or triggerfish (Paresthesias, numbness)
    9. Paralytic Shellfish Poisoning (Saxitoxin) in clams and mussels (numbness, paralysis)
    10. Toxoplasmosis (Headaches, Blurred Vision)
    11. Scombroid Fish Poisoning (perioral Paresthesias, Urticaria, facial Flushing)
  3. Jaundice
    1. Amatoxin Mushrooms
    2. Hepatitis A
  4. Hemorrhagic or necrotic Bullae
    1. Vibrio vulnificus

VIII. Symptoms: Onset Timing

  1. Preformed Toxin with immediate onset (<1 hour)
    1. Tetrodotoxin (pufferfish, porcupinefish, ocean sunfish, or triggerfish)
    2. Scombroid Fish Poisoning
  2. Preformed toxin with 1-6 hour onset (early onset Vomiting and Diarrhea after ingestion)
    1. Bacillus Cereus
    2. Staphylococcus aureus
    3. Norovirus
    4. Ciguatera Poisoning (Reef fish ingestion such as grouper, snapper, barracuda)
  3. Onset within 6-48 hours of ingestion
    1. Bacillus Cereus
    2. Clostridium perfringens
    3. Nontyphoidal Salmonella
    4. Vibrio species
    5. Listeria monocytogenes
    6. Enterotoxigenic Escherichia coli (Traveler's Diarrhea)
  4. Onset within 2-7 days of ingestion
    1. Campylobacter jejuni
    2. Shigella
    3. Shiga-toxin producing E. coli (e.g. E. coli 0157:H7, Enterohemorrhagic E. coli)
    4. Yersinia enterocolitica
  5. Onset >7 days from ingestion
    1. Cyclospora
    2. Cryptosporidium
    3. Toxoplasmosis
    4. Hepatitis A
    5. Salmonella typhi
    6. Entamoeba histolytica
  6. Prolonged duration of Diarrhea
    1. See Chronic Diarrhea
    2. Parasitic Infections (see Serious Parasitic Gastrointestinal Complications)
    3. Noninfectious Chronic Diarrhea
      1. Diarrhea due to Malabsorption (Chronic Fatty Diarrhea)
      2. Chronic Watery Diarrhea (including Drug-Induced Diarrhea)

IX. Differential Diagnosis

  1. See Diarrhea
  2. See Infectious Diarrhea Causes
  3. See Waterborne Illness
  4. Acute Cholecystitis
  5. Acute Hepatitis
  6. Diverticulitis
  7. Inflammatory Bowel Disease (Crohn's Disease, Ulcerative Colitis)
  8. Mesenteric Ischemia

X. Evaluation

  1. See Diarrhea

XI. Management

  1. See Acute Diarrhea
  2. See Diarrhea Management in Children
  3. See Traveler's Diarrhea Management

XII. Prevention

  1. See Foodborne Illness Prevention
  2. See Waterborne Illness Prevention

XIII. Resources

  1. CDC Foodborne Illness Index
    1. http://www.cdc.gov/foodsafety/diseases/
  2. CDC Foodbourne Outbreaks
    1. http://www.cdc.gov/foodsafety/outbreaks/multistate-outbreaks/outbreaks-list.html
    2. http://wwwn.cdc.gov/foodborneoutbreaks/
  3. CDC Foodborne Illness Statistics
    1. http://www.cdc.gov/foodborneburden/
  4. CDC Foodbourne Illness
    1. http://www.fda.gov/Food/ResourcesForYou/Consumers/ucm103263.htm

XIV. References

  1. Glauser and Schafer (2020) Crit Dec Emerg Med 34(1):3-12
  2. Barr (2014) Am Fam Physician 89(3): 180-9 [PubMed]
  3. Scallen (2011) Emerg Infect Dis 17(1): 7-15 [PubMed]
  4. Switaj (2015) Am Fam Physician 92(5): 358-65 [PubMed]

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