Welcome to NGC. Skip directly to: Search Box, Navigation, Content.


Complete Summary

GUIDELINE TITLE

Diagnosis and management of foodborne illnesses: a primer for physicians and other health care professionals.

BIBLIOGRAPHIC SOURCE(S)

GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Diagnosis and management of foodborne illnesses: a primer for physicians. MMWR Recomm Rep 2001 Jan 26;50 (RR-2):1-69.

** REGULATORY ALERT **

FDA WARNING/REGULATORY ALERT

Note from the National Guideline Clearinghouse (NGC): This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

COMPLETE SUMMARY CONTENT

 ** REGULATORY ALERT **
 SCOPE
 METHODOLOGY - including Rating Scheme and Cost Analysis
 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS
 QUALIFYING STATEMENTS
 IMPLEMENTATION OF THE GUIDELINE
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

SCOPE

DISEASE/CONDITION(S)

Foodborne illnesses ("foodborne illnesses" include any illness that is related to food ingestion; gastrointestinal tract symptoms are the most common clinical manifestations of foodborne illnesses).

GUIDELINE CATEGORY

Diagnosis
Evaluation
Management
Treatment

CLINICAL SPECIALTY

Emergency Medicine
Family Practice
Infectious Diseases
Internal Medicine
Pediatrics
Preventive Medicine

INTENDED USERS

Physicians

GUIDELINE OBJECTIVE(S)

To help physicians and other health professionals in the prevention and control of food-related disease outbreaks by providing practical and concise information on the diagnosis, treatment, and reporting of foodborne illnesses

TARGET POPULATION

Infants, children, adolescents and adults

INTERVENTIONS AND PRACTICES CONSIDERED

Diagnosis

  1. Differential diagnosis:
    • Evaluation for signs and symptoms
    • Differentiation between foodborn illness and viral syndromes
    • Duration
    • Associated foods
    • Evaluation for underlying medical conditions (e.g., irritable bowel syndrome, inflammatory bowel disease, Crohn's disease)
  2. Microbiology testing:
    • Stool cultures
    • Blood cultures
    • Direct antigen detection tests and molecular biology techniques

Treatment

  1. Supportive care
  2. Oral and/or intravenous hydration, with fluid +/- electrolyte replacement
  3. Gastric lavage
  4. Pharmacotherapy (penicillin, ciprofloxacin, erythromycin, trimethoprim-sulfamethoxazole, ampicillin, gentamicin, rifampin, doxycycline, ceftazidime, tetracycline, quinolones, bismuth sulfate, metronidazole, iodoquinol, paromomycin, spiramycin, pyrimethamine, nitazoxanide, mebendazole, albendazole, sulfadiazine, methylene blue, atropine, pralidoxime, antihistamines, corticosteroids, nalidixic acid, intravenous mannitol)
  5. Botulinum antitoxin and botulism immune globulin

Surveillance and Reporting

  1. Report potential foodborne illness
  2. Contact local or state health department with specific notifiable disease
  3. Report increases in unusual illnesses, symptom complexes, or disease complexes to public health authorities
  4. Follow the most current information on food safety

MAJOR OUTCOMES CONSIDERED

Disease outbreaks

METHODOLOGY

METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

NUMBER OF SOURCE DOCUMENTS

Not stated

METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

METHODS USED TO ANALYZE THE EVIDENCE

Review

DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

COST ANALYSIS

A formal cost analysis was not performed and published cost analyses were not reviewed.

METHOD OF GUIDELINE VALIDATION

Peer Review

DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Diagnosing Foodborne Illnesses

Differential Diagnosis

The presentation of a patient with a foodborne illness is often only slightly different from that of a patient who presents with a viral syndrome. In addition, viral syndromes are so common that it is reasonable to assume that a percentage of those diagnosed with a viral syndrome have actually contracted a foodborne illness. Therefore, the viral syndrome must be excluded in order to suspect the foodborne illness and take appropriate public health action. Fever, diarrhea, and abdominal cramps can be present or absent in both cases so they are not very helpful. The absence of myalgias or arthralgias would make a viral syndrome less likely and a foodborne illness (that does not target the neurologic system) more likely. Foodborne illnesses that do target the neurologic system tend to cause paraesthesias, weakness and paralysis that are distinguishable from myalgias or arthralgias (see below). The presence of dysentery (bloody diarrhea) is also more indicative of a foodborne illness, particularly if it is early in the course.

If any of the following signs and symptoms occur, alone or in combination, laboratory testing may provide important diagnostic clues (particular attention should be given to very young and elderly patients and to immunocompromised patients, all of whom are more vulnerable):

  • Bloody diarrhea;
  • Weight loss;
  • Diarrhea leading to dehydration;
  • Fever;
  • Prolonged diarrhea (3 or more unformed stools per day, persisting several days);
  • Neurologic involvement such as paresthesias, motor weakness, cranial nerve palsies;
  • Sudden onset of nausea, vomiting, diarrhea;
  • Severe abdominal pain.

In addition to foodborne causes, a differential diagnosis of gastrointestinal tract disease should include underlying medical conditions such as irritable bowel syndrome; inflammatory bowel diseases such as Crohn's disease or ulcerative colitis; malignancy; medication use (including antibiotic-related Clostridium difficile toxin colitis); gastrointestinal tract surgery or radiation; malabsorption syndromes; immune deficiencies; and numerous other structural, functional, and metabolic etiologies. Consideration also should be given to exogenous factors such as the association of the illness with travel, occupation, emotional stress, sexual practices, exposure to other ill persons, recent hospitalization, child care center attendance, and nursing home residence.

The table below presents a list of etiologic agents to consider for various manifestations of foodborne illnesses.

Clinical Presentation Potential Food-Related Agents to Consider
Gastroenteritis (vomiting as primary symptom; fever and/or diarrhea also may be present) Viral gastroenteritis, most commonly rotavirus in an infant or norovirus and other caliciviruses in an older child or adult; or food poisoning due to preformed toxins (e.g., vomitoxin, Staphylococcus aureus toxin, Bacillus cereus toxin) and heavy metals.
Noninflammatory diarrhea (acute watery diarrhea without fever/dysentery; some cases may present with fever)* Can be caused by virtually all enteric pathogens (bacterial, viral, parasitic) but is a classic symptom of:
  • Enterotoxigenic Escherichia coli
  • Giardia
  • Vibrio cholerae
  • Enteric viruses (astroviruses, noroviruses and other caliciviruses, enteric adenovirus, rotavirus)
  • Cryptosporidium
  • Cyclospora cayetanensis
Inflammatory diarrhea (invasive gastroenteritis; grossly bloody stool and fever may be present)**
  • Shigella species
  • Campylobacter species
  • Salmonella species
  • Enteroinvasive Escherichia coli
  • Enterohemorrhagic Escherichia coli
  • Escherichia coli O157:H7
  • Vibrio parahaemolyticus
  • Yersinia enterocolitica
  • Entamoeba histolytica
Persistent diarrhea (lasting >14 days) Prolonged illness should prompt examination for parasites, particularly in travelers to mountainous or other areas where untreated water is consumed. Consider Cyclospora cayetanensis, Cryptosporidium, Entamoeba histolytica, and Giardia lamblia.
Neurologic manifestations (e.g., paresthesias, respiratory depression, bronchospasm, cranial nerve palsies)
  • Botulism (Clostridium botulinum toxin)
  • Organophosphate pesticides
  • Thallium poisoning
  • Scombroid fish poisoning (histamine, saurine)
  • Ciguatera fish poisoning (ciguatoxin)
  • Tetrodon fish poisoning (tetrodotoxin)
  • Neurotoxic shellfish poisoning (brevitoxin)
  • Paralytic shellfish poisoning (saxitoxin)
  • Amnesic shellfish poisoning (domoic acid)
  • Mushroom poisoning
  • Guillain-Barré Syndrome (associated with infectious diarrhea due to Campylobacter jejuni)
Systemic illness (e.g., fever, weakness, arthritis, jaundice)
  • Listeria monocytogenes
  • Brucella species
  • Trichinella spiralis
  • Toxoplasma gondii
  • Vibrio vulnificus
  • Hepatitis A and E viruses
  • Salmonella Typhi and Salmonella Paratyphi
  • Amebic liver abscess

* Noninflammatory diarrhea is characterized by mucosal hypersecretion or decreased absorption without mucosal destruction and generally involves the small intestine. Some affected patients may be dehydrated because of severe watery diarrhea and may appear seriously ill. This is more common in the young and the elderly. Most patients experience minimal dehydration and appear mildly ill with scant physical findings. Illness typically occurs with abrupt onset and brief duration. Fever and systemic symptoms usually are absent (except for symptoms related directly to intestinal fluid loss).

** Inflammatory diarrhea is characterized by mucosal invasion with resulting inflammation and is caused by invasive or cytotoxigenic microbial pathogens. The diarrheal illness usually involves the large intestine and may be associated with fever, abdominal pain and tenderness, headache, nausea, vomiting, malaise, and myalgia. Stools may be bloody and may contain many fecal leukocytes.

Clinical Microbiology Testing

Stool cultures are indicated if the patient is immunocompromised, febrile, has bloody diarrhea, has severe abdominal pain, or if the illness is clinically severe or persistent. Stool cultures are also recommended if many fecal leukocytes are present. This indicates diffuse colonic inflammation and is suggestive of invasive bacterial pathogens such as Shigella, Salmonella, and Campylobacter species, and invasive Escherichia coli. In most laboratories, routine stool cultures are limited to screening for Salmonella and Shigella species, and Campylobacter jejuni/coli. Cultures for Vibrio and Yersinia species, Escherichia coli O157:H7, and Campylobacter species other than jejuni/coli require additional media or incubation conditions and therefore require advance notification or communication with laboratory and infectious disease personnel.

Stool examination for parasites generally is indicated for patients with suggestive travel histories, who are immunocompromised, who suffer chronic or persistent diarrhea, or when the diarrheal illness is unresponsive to appropriate antimicrobial therapy. Stool examination for parasites is also indicated for gastrointestinal tract illnesses that appear to have a long incubation period. Requests for ova and parasite examination of a stool specimen will often enable identification of Giardia lamblia and Entamoeba histolytica, but a special request may be needed for detection of Cryptosporidium and Cyclospora cayetanensis. Each laboratory may vary in its routine procedures for detecting parasites so it is important to contact your laboratory.

Blood cultures should be obtained when bacteremia or systemic infection are suspected.

Direct antigen detection tests and molecular biology techniques are available for rapid identification of certain bacterial, viral, and parasitic agents in clinical specimens. In some circumstances, microbiologic and chemical laboratory testing of vomitus or implicated food items also is warranted. For more information on laboratory procedures for the detection of foodborne pathogens, consult an appropriate medical specialist, clinical microbiologist, or state public health laboratory.

Treating Foodborne Illnesses

Selection of appropriate treatment depends on identification of the responsible pathogen (if possible) and determining if specific therapy is available. Many episodes of acute gastroenteritis are self-limiting and require fluid replacement and supportive care. Oral rehydration is indicated for patients who are mildly to moderately dehydrated; intravenous therapy may be required for more severe dehydration. Routine use of antidiarrheal agents is not recommended because many of these agents have potentially serious adverse effects in infants and young children. Choice of antimicrobial therapy should be based on:

  • Clinical signs and symptoms;
  • Organism detected in clinical specimens;
  • Antimicrobial susceptibility tests; and
  • Appropriateness of treating with an antibiotic (some enteric bacterial infections are best not treated).

Knowledge of the infectious agent and its antimicrobial susceptibility pattern allows the physician to initiate, change, or discontinue antimicrobial therapy. Such information also can support public health surveillance of infectious disease and antimicrobial resistance trends in the community. Antimicrobial resistance has increased for some enteric pathogens, which requires judicious use of this therapy.

Suspected cases of botulism are treated with botulinum antitoxin. Equine botulinum antitoxin for types A, B, and E can prevent the progression of neurologic dysfunction if administered early in the course of illness. Physicians and other health care professionals should notify their local and state health departments regarding suspected cases of botulism. The Centers for Disease Control and Prevention (CDC) maintains a 24-hour consultation service to assist health care professionals with the diagnosis and management of this rare disease.

The following tables summarize diagnostic features, laboratory testing and treatment for bacterial, viral, parasitic, and noninfectious causes of foodborne illness. (Note: To print the following large tables, users may have to change their printer settings to landscape, print on legal size paper, and/or use a small font size.)

Foodborne Illnesses (Bacterial)

Etiology Incubation Period Signs and Symptoms Duration of Illness Associated Foods Laboratory Testing Treatment
Bacillus anthracis 2 days to weeks Nausea, vomiting, malaise, bloody diarrhea, acute abdominal pain. Weeks Insufficiently cooked contaminated meat. Blood. Penicillin is first choice for naturally acquired gastrointestinal anthrax. Ciprofloxacin is second option.
Bacillus cereus (preformed enterotoxin) 1 to 6 hours Sudden onset of severe nausea and vomiting. Diarrhea may be present. 24 hours Improperly refrigerated cooked and fried rice, meats. Normally a clinical diagnosis. Clinical laboratories do not routinely identify this organism. If indicated, send stool and food specimens to reference laboratory for culture and toxin identification. Supportive care.
Bacillus cereus (diarrheal toxin) 10 to 16 hours Abdominal cramps, watery diarrhea, nausea. 24 to 48 hours Meats, stews, gravies, vanilla sauce. Testing not necessary, self-limiting (consider testing food and stool for toxin in outbreaks). Supportive care
Brucella abortus, Brucella melitensis, and Brucella suis 7 to 21 days Fever, chills, sweating, weakness, headache, muscle and joint pain, diarrhea, bloody stools during acute phase. Weeks Raw milk, goat cheese made from unpasteurized milk, contaminated meats. Blood culture and positive serology. Acute: Rifampin and doxycycline daily for >6 weeks. Infections with complications require combination therapy with rifampin, tetracycline and an aminoglycoside.
Campylobacter jejuni 2 to 5 days Diarrhea, cramps, fever, and vomiting; diarrhea may be bloody. 2 to 10 days Raw and undercooked poultry, unpasteurized milk, contaminated water. Routine stool culture; Campylobacter requires special media and incubation at 42 degrees C to grow. Supportive care. For severe cases, antibiotics such as erythromycin and quinolones may be indicated early in the diarrheal disease. Guillain-Barré syndrome can be a sequelae.
Clostridium botulinum-children and adults (preformed toxin) 12 to 72 hours Vomiting, diarrhea, blurred vision, diplopia, dysphagia, and descending muscle weakness. Variable (from days to months). Can be complicated by respiratory failure and death. Home-canned foods with a low acid content, improperly canned commercial foods, home-canned or fermented fish, herb-infused oils, baked potatoes in aluminum foil, cheese sauce, bottled garlic, foods held warm for extended periods of time (e.g. in a warm oven). Stool, serum, and food can be tested for toxin. Stool and food can also be cultured for the organism. These tests can be performed at some state health department laboratories and the Centers for Disease Control and Prevention (CDC). Supportive care. Botulinum antitoxin is helpful if given early in the course of the illness.
Clostridium botulinum-infants 3 to 30 days In infants <12 months, lethargy, weakness, poor feeding, constipation, hypotonia, poor head control, poor gag and sucking reflex. Variable Honey, home-canned vegetables and fruits, corn syrup. Stool, serum, and food can be tested for toxin. Stool and food can also be cultured for the organism. These tests can be performed at some state health department laboratories and the CDC. Supportive care. Botulism immune globulin can be obtained from the Infant Botulism Prevention Program, Health and Human Services, California. Botulinum antitoxin is generally not recommended for infants.
Clostridium perfringens toxin 8 to 16 hours Watery diarrhea, nausea, abdominal cramps; fever is rare. 24 to 48 hours Meats, poultry, gravy, dried or precooked foods, time- and/or temperature-abused food. Stools can be tested for enterotoxin and cultured for organism. Because Clostridium perfringens can normally be found in stool, quantitative cultures must be done. Supportive care. Antibiotics not indicated.
Enterohemorrhagic Escherichia coli (EHEC) including Escherichia coli 0157:H7 and other Shiga toxin-producing Escherichia coli (STEC) 1 to 8 days Severe diarrhea that is often bloody, abdominal pain and vomiting. Usually little or no fever is present. More common in children <4 years. 5 to 10 days Undercooked beef especially hamburger, unpasteurized milk and juice, raw fruits and vegetables (e.g. sprouts), salami (rarely), and contaminated water. Stool culture; Escherichia coli 0157:H7 requires special media to grow. If Escherichia coli 0157:H7 is suspected, specific testing must be requested. Shiga toxin testing may be done using commercial kits; positive isolates should be forwarded to public health laboratories for confirmation and serotyping. Supportive care, monitor renal function, hemoglobin, and platelets closely. Studies indicate that antibiotics may be harmful. Escherichia coli 0157:H7 infection is also associated with hemolytic uremic syndrome (HUS), which can cause lifelong complications. Studies indicate that antibiotics may promote the development of HUS.
Enterotoxigenic Escherichia coli (ETEC) 1 to 3 days Watery diarrhea, abdominal cramps, some vomiting. 3 to >7 days Water or food contaminated with human feces. Stool culture. ETEC requires special laboratory techniques for identification. If suspected, must request specific testing. Supportive care. Antibiotics are not needed except in rare cases. Recommended antibiotics include TMP-SMX and quinolones.
Listeria monocytogenes 9 to 48 hours for gastrointestinal symptoms, 2 to 6 weeks for invasive disease. Fever, muscle aches, and nausea or diarrhea. Pregnant women may have mild flu-like illness, and infection can lead to premature delivery or stillbirth. Elderly or immunocompromised patients may have bacteremia or meningitis. Variable Fresh soft cheeses, unpasteurized milk, inadequately pasteurized milk, ready-to-eat deli meats, hot dogs. Blood or cerebrospinal fluid cultures. Asymptomatic fecal carriage occurs; therefore, stool culture usually not helpful. Antibody to listeriolysin O may be helpful to identify outbreak retrospectively. Supportive care and antibiotics; Intravenous ampicillin, penicillin, or TMP-SMX are recommended for invasive disease.
  At birth and infancy Infants infected from mother at risk for sepsis or meningitis.        
Salmonella species 1 to 3 days Diarrhea, fever, abdominal cramps, vomiting. Salmonella typhi and Salmonella paratyphi produce typhoid with insidious onset characterized by fever, headache, constipation, malaise, chills, and myalgia; diarrhea is uncommon, and vomiting is usually not severe. 4 to 7 days Contaminated eggs, poultry, unpasteurized milk or juice, cheese, contaminated raw fruits and vegetables (alfalfa sprouts, melons). Salmonella typhi epidemics are often related to fecal contamination of water supplies or street-vended foods. Routine stool cultures. Supportive care. Other than for Salmonella typhi, antibiotics are not indicated unless there is extra-intestinal spread, or the risk of extra-intestinal spread, of the infection. Consider ampicillin, gentamicin, TMP-SMX, or quinolones if indicated. A vaccine exists for Salmonella typhi.
Shigella species 24 to 48 hours Abdominal cramps, fever, and diarrhea. Stools may contain blood and mucus. 4 to 7 days Food or water contaminated with fecal material. Usually person-to-person spread, fecal-oral transmission. Ready-to-eat foods touched by infected food workers(e.g., raw vegetables, salads, sandwiches). Routine stool cultures. Supportive care. TMP-SMX recommended in the United States if organism is susceptible; nalidixic acid or other quinolones may be indicated if organism is resistant, especially in developing countries.
Staphylococcus aureus (preformed enterotoxin) 1 to 6 hours Sudden onset of severe nausea and vomiting. Abdominal cramps. Diarrhea and fever may be present. 24 to 48 hours Unrefrigerated or improperly refrigerated meats, potato and egg salads, cream pastries. Normally a clinical diagnosis. Stool, vomitus, and food can be tested for toxin and cultured if indicated. Supportive care.
Vibrio cholerae (toxin) 24 to 72 hours Profuse watery diarrhea and vomiting, which can lead to severe dehydration and death within hours. 3 to 7 days. Causes life-threatening dehydration. Contaminated water, fish, shellfish, street-vended food typically from Latin America or Asia. Stool culture; Vibrio cholerae requires special media to grow. If Vibrio cholerae is suspected, must request specific testing. Support care with aggressive oral and intravenous rehydration. In cases of confirmed cholera, tetracycline or doxycycline is recommended for adults and TMP-SMX for children (<8 years).
Vibrio parahaemolyticus 2 to 48 hours Watery diarrhea, abdominal cramps, nausea, vomiting. 2 to 5 days Undercooked or raw seafood, such as fish, shellfish. Stool cultures. Vibrio parahaemolyticus requires special media to grow. If Vibrio parahaemolyticus is suspected, must request specific testing. Supportive care. Antibiotics are recommended in severe cases: tetracycline, doxycycline, gentamicin, and cefotaxime.
Vibrio vulnificus 1 to 7 days Vomiting, diarrhea, abdominal pain, bacteremia, and wound infections. More common in the immunocompromised, or in patients with chronic liver disease (presenting with bullous skin lesions). Can be fatal in patients with liver disease and the immunocompromised. 2 to 8 days Undercooked or raw shellfish, especially oysters; other contaminated seafood, and open wounds exposed to seawater. Stool, wound, or blood cultures. Vibrio vulnificus requires special media to grow. If Vibrio vulnificus is suspected, must request specific testing. Supportive care and antibiotics; tetracycline, doxycycline, and ceftazidime are recommended.
Yersinia enterocolitica and Yersinia pseudotuberculosis 24 to 48 hours Appendicitis-like symptoms (diarrhea and vomiting, fever, and abdominal pain) occur primarily in older children and young adults. May have a scarlatiniform rash with Yersinia pseudotuberculosis. 1 to 3 weeks, usually self-limiting Undercooked pork, unpasteurized milk, tofu, contaminated water. Infection has occurred in infants whose caregivers handled chitterlings. Stool, vomitus or blood culture. Yersinia requires special media to grow. If suspected, must request specific testing. Serology is available in research and reference laboratories. Supportive care, usually self-limiting. If septicemia or other invasive disease occurs, antibiotic therapy with gentamicin or cefotaxime (doxycycline and ciprofloxacin also effective).

Foodborne Illnesses (Viral)

Etiology Incubation Period Signs and Symptoms Duration of Illness Associated Foods Laboratory Testing Treatment
Hepatitis A 28 days average (15 to 50 days) Diarrhea; dark urine; jaundice; and flu-like symptoms (i.e., fever, headache, nausea, and abdominal pain). Variable, 2 weeks to 3 months Shellfish harvested from contaminated waters, raw produce, contaminated drinking water, uncooked foods and cooked foods that are not reheated after contact with infected food handler. Increase in alanine transferase (ALT), bilirubin. Positive IgM and anti-hepatitis A antibodies. Supportive care. Prevention with immunization.
Noroviruses (and other caliciviruses) 12 to 48 hours Nausea, vomiting, abdominal cramping, diarrhea fever, myalgia, and some headache. Diarrhea is more prevalent in adults and vomiting is more prevalent in children. 12 to 60 hours Shellfish, fecally contaminated foods, ready-to-eat foods touched by infected food workers (salads, sandwiches, ice, cookies, fruit). Routine reverse-transcriptase polymerase chain reaction (RT-PCR) and electron microscopy (EM) on fresh unpreserved stool samples. Clinical diagnosis, negative bacterial cultures. Stool is negative for white blood cells. Supportive care such as rehydration. Good hygiene.
Rotavirus 1 to 3 days Vomiting, watery diarrhea, low-grade fever. Temporary lactose intolerance may occur. Infants and children, elderly, and immunocompromised are especially vulnerable. 4 to 8 days Fecally contaminated foods. Ready-to-eat foods touched by infected food workers (salads, fruits). Identification of virus in stool via immunoassay. Supportive care. Severe diarrhea may require fluid and electrolyte replacement.
Other viral agents (astroviruses, caliciviruses, adenoviruses, parvoviruses) 10 to 70 hours Nausea, vomiting, diarrhea, malaise, abdominal pain, headache, fever 2 to 9 days Fecally contaminated foods. Ready-to-eat foods touched by infected food workers. Some shellfish. Identification of the virus in early acute stool samples. Serology. Commercial enzyme-linked immunosorbent assay (ELISA) kits are now available to adenoviruses and astroviruses. Supportive care, usually mild, self-limiting. Good hygiene.

Foodborne Illnesses (Parasitic)

Etiology Incubation Period Signs and Symptoms Duration of Illness Associated Foods Laboratory Testing Treatment
Angiostrongylus cantonensis 1 week to >1 month Severe headaches, nausea, vomiting, neck stiffness, paresthesias, hyperesthesias, seizures, and other neurologic abnormalities. Several weeks to several months Raw or undercooked intermediate hosts (e.g., snails or slugs), infected paratenic (transport) hosts (e.g., crabs, fresh water shrimp), fresh produce contaminated with intermediate or transport hosts. Examination of cerebrospinal fluid (CSF) for elevated pressure, protein, leukocytes, and eosinophils; serologic testing using ELISA to detect antibodies to Angiostrongylus cantonensis. Supportive care. Repeat lumbar punctures and use of corticosteroid therapy may be used for more severely ill patients.
Cryptosporidium 2 to 10 days Diarrhea usually watery), stomach cramps, upset stomach, slight fever. May be remitting and relapsing over weeks to months Any uncooked food or food contaminated by an ill food handler after cooking, drinking water. Request specific examination of the stool for Cryptosporidium. May need to examine water or food. Supportive care, self-limited. If severe consider paromomycin for 7 days. For children aged 1-11 years, consider nitazoxanide for 3 days.
Cyclospora cayetanensis 1 to 14 days, usually at least 1 week Diarrhea (usually watery), loss of appetite, substantial loss of weight, stomach cramps, nausea, vomiting, fatigue. May be remitting and relapsing over weeks to months Various types of fresh produce (imported berries, lettuce) Request specific examination of the stool for Cyclospora. May need to examine water or food. TMP-SMX for 7 days.
Entamoeba histolytica 2 to 3 days to 1 to 4 weeks Diarrhea (often bloody), frequent bowel movements, lower abdominal pain. May be protracted (several weeks to several months) Any uncooked food or food contaminated by an ill food handler after cooking, drinking water. Examination of stool for cysts and parasites-at least 3 samples. Serology for long-term infections. Metronidazole and a luminal agent (iodoquinol or paromomycin).
Giardia lamblia 1 to 2 weeks Diarrhea, stomach cramps, gas. Days to weeks Any uncooked food or food contaminated by an ill food handler after cooking, drinking water. Examination of stool for ova and parasites- may need at least 3 samples. Metronidazole.
Toxoplasma gondii 5 to 23 days Generally asymptomatic, 20% may develop cervical lymphadenopathy and/or a flu-like illness.

In immunocompromised patients: central nervous system (CNS) disease, myocarditis, or pneumonitis is often seen.
Months Accidental ingestion of contaminated substances (e.g., soil contaminated with cat feces, on fruits and vegetables, raw or partly cooked meat [especially pork, lamb, or venison]). Isolation of parasites from blood or other body fluids; observation of parasites in patient specimens via microscopy or histology. Detection of organisms is rare, serology (reference laboratory needed) can be a useful adjunct in diagnosing toxoplasmosis. However, lgM antibodies may persist for 6 to 18 months and thus may not necessarily indicate recent infection. PCR of bodily fluids.

For congenital infection: isolation of Toxoplasma gondii from placenta, umbilical cord, or infant blood. PCR of white blood cells, cerebrospinal fluid or amniotic fluid, or IgM and IgA serology, performed by a reference laboratory.
Asymptomatic healthy, but infected, persons do not require treatment. Spiramycin or pyrimethamine plus sulfadiazine may be used for immunocompromised persons, in specific cases. Pyrimethamine plus sulfadiazine (with or without steroids) may be given for ocular disease when indicated. Folinic acid is given with pyrimethamine plus sulfadiazine to counteract bone marrow suppression.
Toxoplasma gondii (congenital infection) In infants at birth Treatment of the mother may reduce severity and/or incidence of congenital infection. Most infected infants have few symptoms at birth. Later, they will generally develop signs of congenital toxoplasmosis (mental retardation, severely impaired eyesight, cerebral palsy, seizures) unless the infection is treated. Months Passed from mother (who acquired acute infection during pregnancy) to child.    
Trichinella spiralis 1 to 2 days for initial symptoms; others begin 2 to 8 weeks after infection Acute: nausea, vomiting, diarrhea, fatigue, fever, abdominal discomfort followed by muscle soreness, weakness, and occasional cardiac and neurologic complications. Months Raw or undercooked contaminated meat, usually pork or wild game meat (e.g., bear or moose). Positive serology or demonstration of larvae via muscle biopsy. Increase in eosinophils. Supportive care plus mebendazole or albendazole.

Foodborne Illnesses (Non-Infectious)

Etiology Incubation Period Signs and Symptoms Duration of Illness Associated Foods Laboratory Testing Treatment
Antimony 5 minutes to 8 hours; usually <1 hour Vomiting, metallic taste. Usually self-limited Metallic container. Identification of metal in beverage or food. Supportive care.
Arsenic Few hours Vomiting, colic, diarrhea. Several days Contaminated food. Urine. May cause eosinophilia. Gastric lavage, bronchoalveolar lavage (BAL), (dimercaprol).
Cadmium 5 minutes to 8 hours; usually <1 hour Nausea, vomiting, myalgia, increase in salivation, stomach pain. Usually self-limited Seafood, oysters, clams, lobster, grains, peanuts. Identification of metal in food. Supportive care.
Ciguatera fish poisoning (ciguatera toxin) 2 to 6 hours Gastrointestinal: abdominal pain, nausea, vomiting, diarrhea. Days to weeks to months A variety of large reef fish. Grouper, red snapper, amberjack, and barracuda (most common). Radioassay for toxin in fish or a consistent history. Supportive care, intravenous mannitol. Children more vulnerable.
  3 hours Neurologic: paresthesias, reversal of hot or cold, pain, weakness.        
  2 to 5 days Cardiovascular: bradycardia, hypotension, increase in T wave abnormalities.        
Copper 5 minutes to 8 hours; usually <1 hour Nausea, vomiting, blue or green vomitus. Usually self-limited Metallic container. Identification of metal in beverage or food. Supportive care.
Mercury 1 week or longer Numbness, weakness of legs, spastic paralysis, impaired vision, blindness, coma. Pregnant women and the developing fetus are especially vulnerable. May be protracted Fish exposed to organic mercury, grains treated with mercury fungicides. Analysis of blood, hair. Supportive care.
Mushroom toxins, short-acting (museinol, muscarine, psilocybin, coprinus artemetaris, ibotenic acid) <2 hours Vomiting, diarrhea, confusion, visual disturbance, salivation, diaphoresis, hallucinations, disulfiram-like reaction, confusion, visual disturbance. Self-limited Wild mushrooms (cooking may not destroy these toxins). Typical syndrome and mushroom identified or demonstration of the toxin. Supportive care.
Mushroom toxin, long-acting (amanitin) 4 to 8 hours diarrhea; 24 to 48 hours liver failure Diarrhea, abdominal cramps, leading to hepatic and renal failure. Often fatal Mushrooms. Typical syndrome and mushroom identified and/or demonstration of the toxin. Supportive care; life-threatening, may need life support.
Nitrite poisoning 1 to 2 hours Nausea, vomiting, cyanosis, headache, dizziness, weakness, loss of consciousness, chocolate-brown colored blood. Usually self-limited Cured meats, any contaminated foods, spinach exposed to nitrification. Analysis of the food, blood. Supportive care, methylene blue.
Pesticides (organophosphates or carbamates) Few minutes to few hours Nausea, vomiting, abdominal cramps, diarrhea, headache, nervousness, blurred vision, twitching, convulsions, salivation and meiosis. Usually self-limited Any contaminated food. Analysis of the food, blood. Atropine. 2-PAM (Pralidoxime) is used when atropine is not able to control symptoms and is rarely necessary in carbamate poisoning
Puffer Fish (tetrodotoxin) <30 minutes Paresthesias, vomiting, diarrhea, abdominal pain, ascending paralysis, respiratory failure. Death usually in 4 to 6 hours Puffer fish. Detection of tetrodotoxin in fish. Life-threatening may need respiratory support.
Scombroid (histamine) 1 min to 3 hours Flushing, rash, burning sensation of skin, mouth and throat, dizziness, urticaria, paresthesias. 3 to 6 hours Fish: bluefin, tuna, skipjack, mackerel, marlin, escolar, and mahi mahi. Demonstration of histamine in food or clinical diagnosis. Supportive care, antihistamines.
Shellfish toxins (diarrheic, neurotoxic, amnesic) Diarrheic shellfish poisoning (DSP)-30 min to 2 hours Nausea, vomiting, diarrhea, and abdominal pain accompanied by chills, headache, and fever. Hours to 2-3 days A variety of shellfish, primarily mussels, oysters, scallops, and shellfish from the Florida coast and the Gulf of Mexico. Detection of the toxin in shellfish; high pressure liquid chromatography. Supportive care, generally self-limiting. Elderly are especially sensitive to APS.
  Neurotoxic shellfish poisoning (NSP)-few minutes to hours Tingling and numbness of lips, tongue, and throat, muscular aches, dizziness, reversal of the sensations of hot and cold, diarrhea, and vomiting.        
  Amnesic shellfish poisoning (ASP)-24 to 48 hours Vomiting, diarrhea, abdominal pain and neurological problems such as confusion, memory loss, disorientation, seizure, coma.        
Shellfish toxins (paralytic shellfish poisoning) 30 min to 3 hours Diarrhea, nausea, vomiting leading to paresthesias of mouth, lips, weakness, dysphasia, dysphonia, respiratory paralysis. Days Scallops, mussels, clams, cockles. Detection of toxin in food or water where fish are located; high pressure liquid chromatography. Life-threatening, may need respiratory support.
Sodium fluoride Few min to 2 hours Salty or soapy taste, numbness of mouth, vomiting, diarrhea, dilated pupils, spasms, pallor, shock, collapse. Usually self-limited Dry foods (such as dry milk, flour, baking powder, cake mixes) contaminated with sodium fluoride-containing insecticides and rodenticides. Testing of vomitus or gastric washings. Analysis of the food. Supportive care.
Thallium Few hours Nausea, vomiting, diarrhea, painful paresthesias, motor polyneuropathy, hair loss. Several days Contaminated food. Urine, hair. Supportive care.
Tin 5 min to 8 hours; usually <1 hour Nausea, vomiting, diarrhea. Usually self-limited Metallic container. Analysis of the food. Supportive care.
Vomitoxin Few min to 3 hours Nausea, headache, abdominal pain, vomiting. Usually self-limited Grains, such as wheat, corn, barley. Analysis of the food. Supportive care.
Zinc Few hours Stomach cramps, nausea, vomiting, diarrhea, myalgias. Usually self-limited Metallic container. Analysis of the food, blood and feces, saliva or urine. Supportive care.

Surveillance and Reporting of Foodborne Illnesses

The following lists current reporting requirements for foodborne diseases and conditions in the United States. National reporting requirements are determined collaboratively by the Council of State and Territorial Epidemiologists and the Centers for Disease Control and Prevention (CDC).

Notifiable BACTERIAL Foodborne Diseases and Conditions

  • Anthrax
  • Botulism
  • Brucellosis
  • Cholera
  • Enterohemorrhagic Escherichia coli
  • Hemolytic uremic syndrome, post-diarrheal
  • Listeriosis
  • Salmonellosis (other than Salmonella Typhi)
  • Shigellosis
  • Typhoid fever (Salmonella Typhi and Salmonella Paratyphi infections)

Notifiable VIRAL Foodborne Diseases and Conditions

  • Hepatitis A

Notifiable PARASITIC Foodborne Diseases and Conditions

  • Cryptosporidiosis
  • Cyclosporiasis
  • Giardiasis
  • Trichinellosis

In the United States, additional reporting requirements may be mandated by state and territorial laws and regulations. Details on specific state reporting requirements are available from the:

Typically, the appropriate procedure for physicians to follow in reporting foodborne illnesses is to contact the local or state health department whenever they identify a specific notifiable foodborne disease. However, it is often unclear if a patient has a foodborne illness prior to diagnostic tests, so health care professionals should also report potential foodborne illnesses, such as when two or more patients present with a similar illness that may have resulted from the ingestion of a common food. Local health departments then report the illnesses to the state health department and determine if further investigation is warranted.

In addition to reporting cases of potential foodborne illnesses, it is important for physicians to report noticeable increases in unusual illnesses, symptom complexes, or disease patterns (even without definitive diagnosis) to public health authorities. Prompt reporting of unusual patterns of diarrheal/gastrointestinal tract illness, for example, can allow public health officials to initiate an epidemiologic investigation earlier than would be possible if the report awaited definitive etiologic diagnosis.

CLINICAL ALGORITHM(S)

None provided

EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

Not applicable

BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

POTENTIAL BENEFITS

General benefits include:

Prevent and control food-related disease outbreaks.

Specific benefits include:

Foodborne disease reporting is not only important for disease prevention and control, but more accurate assessments of the burden of foodborne illness in the community occur when physicians report foodborne illnesses to the local or state health department. In addition, reporting of cases of foodborne illness by practicing physicians to the local health department may help the health officer identify a foodborne disease outbreak in the community. This may lead to early identification and removal of contaminated products from the commercial market. Occasionally, reporting may lead to the identification of a previously unrecognized agent of foodborne illness. Reporting also may lead to identification and appropriate management of human carriers of known foodborne pathogens, especially those with high-risk occupations for disease transmission such as food workers.

Subgroups Most Likely to Benefit:

Young, elderly, and immunocompromised patients

POTENTIAL HARMS

Not stated

QUALIFYING STATEMENTS

QUALIFYING STATEMENTS

This primer is not a clinical guideline or definitive resource for the diagnosis and treatment of foodborne illness. Safe food handling practices and technologies (e.g., irradiation, food processing and storage) also are not addressed.

IMPLEMENTATION OF THE GUIDELINE

DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

IOM CARE NEED

Getting Better
Staying Healthy

IOM DOMAIN

Effectiveness

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2001 Jan (revised 2004 Apr 16)

GUIDELINE DEVELOPER(S)

American Medical Association - Medical Specialty Society
Center for Food Safety and Applied Nutrition - Federal Government Agency [U.S.]
Centers for Disease Control and Prevention - Federal Government Agency [U.S.]
Food Safety and Inspection Service - Federal Government Agency [U.S.]

GUIDELINE DEVELOPER COMMENT

This primer was developed collaboratively by the American Medical Association, the Centers for Disease Control and Prevention (CDC), the Center for Food Safety and Nutrition, Food and Drug Administration (U.S.), and the Food Safety and Inspection Service, Department of Agriculture (U.S.) as part of the National Food Safety Initiative implemented under former President William Jefferson Clinton.

SOURCE(S) OF FUNDING

United States Government

GUIDELINE COMMITTEE

Not stated

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Writing/Working Group Members: American Medical Association: LJ Tan, PhD (Working Group Chair); Jim Lyznicki, MS, MPH Centers for Disease Control and Prevention: Penny M. Adcock, MD; Eileen Dunne, MD, MPH; Julia Smith, MPH Center for Food Safety and Applied Nutrition, U.S. Food and Drug Administration: Eileen Parish, MD; Arthur Miller, PhD, Howard Seltzer Food Safety and Inspection Service, U.S. Department of Agriculture: Ruth Etzel, MD, PhD

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Elaine F. Brainerd, R.N., M.A., has indicated that she has a financial relationship with Centers for Disease Control and Prevention (CDC) because she is the Director of a Food Safe Schools project that is funded under a cooperative agreement by CDC. The remaining preparers have signed a conflict of interest disclosure form that verifies no conflict of interest.

GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Diagnosis and management of foodborne illnesses: a primer for physicians. MMWR Recomm Rep 2001 Jan 26;50 (RR-2):1-69.

GUIDELINE AVAILABILITY

Electronic copies: Available from the Centers for Disease Control and Prevention (CDC) Web site.

Print copies: Available from the Centers for Disease Control and Prevention, MMWR, Atlanta, GA 30333. Additional copies can be purchased from the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402-9325; (202) 783-3238. Copies are also available from the American Medical Association, 515 North State Street, Chicago, IL 60610; Web site: www.ama-assn.org.

AVAILABILITY OF COMPANION DOCUMENTS

None available

PATIENT RESOURCES

None available

NGC STATUS

This summary was completed by ECRI on May 8, 2001. This summary was updated on August 17, 2004. This summary was updated by ECRI Institute on July 28, 2008 following the U.S. Food and Drug Administration advisory on fluoroquinolone antimicrobial drugs.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which may be subject to the guideline developer's copyright restrictions. (The original full-text guideline was reprinted in the MMWR, the source cited for this NGC Guideline Summary, with the permission of the American Medical Association; the Center for Food Safety and Nutrition, Food and Drug Administration; and the Food Safety and Inspection Service, U.S. Department of Agriculture.)

DISCLAIMER

NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.


 

 

   
DHHS Logo