Food Poisoning Follow-up
- Author: Roberto M Gamarra, MD; Chief Editor: Julian Katz, MD more...
Further Outpatient Care
Because most cases of food poisoning are self-limited, prolonged follow-up care is not required.
Stool cultures should be monitored in individuals working in hospitals, food establishments, and daycare centers and who are infected with E coli O157:H7 or Salmonella or Shigella organisms until they become culture-negative without antibiotics. These people should not return to work until that time.
For patient education resources, visit Digestive Disorders Center and Healthy Living Center, as well as Abdominal Pain in Adults, Vomiting and Nausea, Diarrhea, Traveler's Diarrhea, and Foreign Travel.
No vaccine is available that can prevent norovirus infection. An early study conducted in a controlled setting assessed the safety, immunogenicity, and efficacy of an investigational, intranasally delivered norovirus viruslike particle (VLP) vaccine to prevent acute viral gastroenteritis. Results suggest the vaccine protects against illness and infection after exposure to the Norwalk virus and could potentially prevent infection in susceptible, high-risk populations. The vaccine has not been tested in the natural setting, however.
The best way to prevent food poisoning caused by infectious agents is to practice strict personal hygiene, cook all foods adequately, avoid cross-contamination of raw and cooked foods, and keep all foods at appropriate temperatures (ie, < 40°F for refrigerated items and >140°F for hot items).
Avoiding eating wild mushrooms prevents mushroom poisoning.
Prevention of fish poisoning requires avoidance of large tropical fish (ciguatera poisoning) and compliance with seasonal or emergency quarantines of shellfish harvesting areas (shellfish poisoning).
Raw or undercooked milk, poultry, eggs, meat, and seafood are best avoided.
Local health authorities should be notified if an outbreak of food poisoning occurs. This leads to appropriate actions to prevent further spread of food poisoning.
Irradiation of food (ie, the use of ionizing radiation or ionizing energy to treat foods, either packaged or in bulk form) can eliminate food-borne pathogens. Annually, more than half a million tons of food is now irradiated worldwide. Treating raw meat and poultry with irradiation at the slaughter plant could eliminate bacteria, such as E coli O157:H7 and Salmonella and Campylobacter organisms. No evidence of adverse health effects has been found in the well-controlled clinical trials involving irradiated food.
The use of low-temperature gas plasmas in the food industry may potentially reduce the incidence of foodborne disease. The gas plasmas have microbiocidal capabilities and may also aid in degrading undesirable chemical compounds that can be found on food and food-processing equipment (eg, pesticide residues, toxins, allergens).
Prophylaxis for traveler's diarrhea is not recommended routinely because of the risk of adverse effects from the drugs (eg, rash, anaphylaxis, vaginal candidiasis) and the development of resistant gut flora. Possible regimens for prophylaxis include bismuth subsalicylate (Pepto-Bismol, 524 mg PO qid with meals and qhs), doxycycline (100 mg PO qd; resistance documented in many areas of the world), TMP/SMX (160 mg/800 mg 1 double-strength tab qd), or norfloxacin (400 mg PO qd; fluoroquinolones should not be prescribed to children or pregnant women). No significant resistance to the fluoroquinolones has been reported in high-risk areas, and they are the most effective antibiotics in regions where susceptibilities are not known.
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|Causative Agents||Source and
|Staphylococci||Improperly stored foods with high salt or sugar content favors growth of staphylococci.
Intense vomiting and watery diarrhea start 1-4 h after ingestion and last as long as 24-48 h
|Enterotoxin acts on receptors in the gut that transmit impulses to the medullary centers||Symptomatic treatment|
|B cereus||Contaminated fried rice (emetic)
Emetic: Duration is 9 h, vomiting and cramps
Diarrheal: Lasts for 24 h
Mainly vomiting after 1-6 h and mainly diarrhea after 8-16 h after ingestion; lasts as long as 1 d
|Emetic enterotoxin (short incubation and duration) - Poorly understood
Diarrheal enterotoxin (long incubation and duration) - Increasing intestinal secretion by activation of adenylate cyclase in intestinal epithelium
|C perfringens||Inadequately cooked meat, poultry, or legumes
Acute onset of abdominal cramps with diarrhea starts 8-24 h after ingestion.
Vomiting is rare. It lasts less than 1 d.
Enteritis necroticans associated with C perfringens type C in improperly cooked pork (40% mortality)
|Enterotoxin produced in the gut, and food causes hypersecretion in the small intestine||Culture of clostridia in food and stool
|C botulinum||Canned foods (eg, smoked fish, mushrooms, vegetables, honey)
Descending weakness and paralysis start 1-4 d after ingestion, followed by constipation.
Mortality is high
|Toxin absorbed from the gut blocks the release of acetylcholine in the neuromuscular junction||Toxin present in food, serum, and stool.
Intravenous trivalent antitoxin from CDC
|Listeria monocytogenes||Raw and pasteurized milk, soft cheeses, raw vegetables, shrimp
Systemic disease associated with bacteremia
Intestinal symptoms precede systemic disease
Can seed meninges, heart valves, and other organs
Highest mortality among bacterial food poisonings
|Highly motile, heat-resistant, gram-positive organism||CSF or blood culture
Must treat with antibiotics if bacteremic
|Enterotoxic E coli (eg, traveler's diarrhea)||Contaminated water and food (eg, salad, cheese, meat)
Acute-onset watery diarrhea starts 24-48 h after ingestion
Concomitant vomiting and abdominal cramps may be present. It lasts for 1-2 d
|Enterotoxin causes hypersecretion in small and large intestine via guanylate cyclase activation||Supportive treatment
|Enterohemorrhagic E coli (eg, E coli O157:H7)||Improperly cooked hamburger meat and previously spinach
Most common isolate pathogen in bloody diarrhea starts 3-4 d after ingestion
Usually progresses from watery to bloody diarrhea. It lasts for 3-8 d
May be complicated by hemolytic-uremic syndrome or thrombotic thrombocytopenic purpura
|Cytotoxin results in endothelial damage and leads to platelet aggregation and microvascular fibrin thrombi||Diagnosis with stool culture
|Enteroinvasive E coli||Contaminated imported cheese
Usually watery diarrhea (some may present with dysentery)
|Enterotoxin produces secretion
Shigalike toxin facilitates invasion
|Enteroaggregative E coli||Implicated in traveler's diarrhea in developing countries
Can cause bloody diarrhea
|Bacteria clump on the cell surfaces||Ciprofloxacin may shorten duration and eradicate the organism|
|V cholera||Contaminated water and food
Large amount of nonbloody diarrhea starts 8-24 h after ingestion. It lasts for 3-5 d
|Enterotoxin causes hypersecretion in small intestine
Infective dose usually is 107 -109 organisms
|Positive stool culture finding
Prompt replacement of fluids and electrolytes (oral rehydration solution)
Tetracycline (or fluoroquinolones) shortens the duration of symptoms and excretion of Vibrio
|V parahaemolyticus||Raw and improperly cooked seafood (ie, mollusks and crustaceans)
Explosive watery diarrhea starts 8-24 h after ingestion
It lasts for 3-5 d
|Enterotoxin causes hypersecretion in small intestine
Hemolytic toxin is lethal
Infective dose is usually 107 -109 organisms
|Positive stool culture
Prompt replacement of fluids and electrolytes
Sensitive to tetracycline, but unclear role for antibiotics
|V vulnificus||Wound infection in salt water or consumption of raw oysters
Can be lethal in patients with liver disease (50% mortality)
Growth correlates with availability of iron (especially transferrin saturation >70%)
|Culture of characteristic bullous lesions or blood
Immediate antibiotics if suspected (eg, doxycycline and ceftriaxone)
|C jejuni||Domestic animals, cattle, chickens
Fecal-oral transmission in humans
Foul-smelling watery diarrhea followed by bloody diarrhea
Abdominal pain and fever also may be present; it starts 1-3 d after exposure and recovery is in 5-8 d
|Uncertain about endotoxin production and invasion||Culture in special media at 42°C
Erythromycin for invasive disease (fever)
|Shigella||Potato, egg salad, lettuce, vegetables, milk, ice cream, and water
Abrupt onset of bloody diarrhea, cramps, tenesmus, and fever starts 12-30 h after ingestion.
Usually self-limited in 3-7 d
|Organisms invade epithelial cells and produce toxins
Infective dose is 102 -103 organisms
Enterotoxin-mediated diarrhea followed by invasion (dysentery/colitis)
|Polymorphonuclear leukocytes (PMNs), blood, and mucus in stool
Positive stool culture
Oral rehydration is mainstay
Trimethoprim-sulfamethoxazole (TMP-SMX) or ampicillin for severe cases
|Salmonella||Beef, poultry, eggs, and dairy products
Abrupt onset of moderate-to-large amount of diarrhea with low-grade fever; in some cases, bloody diarrhea
Abdominal pain and vomiting also present, beginning 6-48 h after exposure and lasts 7-12 d
|Invasion but no toxin production||Positive stool culture finding
Antibiotic for systemic infection
|Yersinia||Pets; transmission in humans by fecal-oral route or contaminated milk or ice cream
Acute abdominal pain, diarrhea, and fever (enterocolitis)
Incubation period not known Polyarthritis and erythema nodosum in children
May mimic appendicitis
|Gastroenteritis and mesenteric adenitis
Direct invasion and enterotoxin
|Polymorphonuclear leukocytes and blood in stool
Positive stool culture finding
No evidence that antibiotics alter the course but may be used in severe infections
|Aeromonas||Untreated well or spring water
Diarrhea may be bloody
May be chronic up to 42 d in the United States
|Enterotoxin, hemolysin, and cytotoxin||Positive stool culture
Fluoroquinolones or TMP/SMX for chronic diarrhea
|Parasitic Food Poisoning||Source and Clinical Features||Pathogenesis||Diagnosis and Treatment|
|E histolytica||Contaminated food and water
Minority may develop liver abscesses
|Invasion of the mucosa by the parasites||Criterion standard is colonoscopy with biopsy
Ova and parasites may be seen in the stool but has low sensitivity
Luminal amebicides (eg, paromomycin)
Tissue amebicides (eg, metronidazole)
|G lamblia||Contaminated ground water
Fecal-oral transmission in humans
Mild diarrhea with nausea and abdominal cramps starts 2-3 d after ingestion; lasts for 1 wk
May become chronic
Highest concentration in the distal duodenum and proximal jejunum
|Initial diagnostic test is stool enzyme-linked immunosorbent assay
Duodenal aspiration or small bowel biopsy
Cyst in the stool
|Seafood/Shellfish Poisoning||Source and
|Paralytic shellfish poisoning||Temperate coastal areas
Source - Bivalve mollusks
Onset usually is 30-60 min
Initial symptoms include perioral and intraoral paresthesia
Other symptoms include paresthesia of the extremities, headache, ataxia, vertigo, cranial nerve palsies, and paralysis of respiratory muscles, resulting in respiratory arrest
|Fish acquires toxin-producing dinoflagellates||General observation for 4-6 h
Maintain patent airway.
Administer oxygen, and assist ventilation if necessary
For recent ingestion, charcoal 50-60 g may be helpful
|Neurotoxic shellfish poisoning||Coastal Florida
Source - Mollusks
Illness is milder than in paralytic shellfish poisoning
|Fish acquires toxin-producing dinoflagellates||Symptomatic|
|Ciguatera||Hawaii, Florida, and Caribbean
Source - Carnivorous reef fish
Vomiting, diarrhea, and cramps start 1-6 h after ingestion and last from days to months
Diarrhea may be accompanied by a variety of neurologic symptoms including paresthesia, reversal of hot and cold sensation, vertigo, headache, and autonomic disturbances such as hypotension and bradycardia
Chronic symptoms (eg, fatigue, headache) may be aggravated by caffeine or alcohol
|Fish acquires toxin-producing dinoflagellates
Toxin increases intestinal secretion by changing intracellular calcium concentration
Anecdotal reports of successful treatment of neurologic symptoms with mannitol 1 g/kg IV
Source - Puffer fish
Onset of symptoms usually is 30-40 min but may be as short as 10 min; it includes lethargy, paresthesia, emesis, ataxia, weakness, and dysphagia; ascending paralysis occurs in severe cases; mortality is high.
|Neurotoxin is concentrated in the skin and viscera of puffer fish.||Symptomatic|
|Scombroid||Source - Tuna, mahi-mahi, kingfish
Allergic symptoms such as skin flush, urticaria, bronchospasm, and hypotension usually start within 15-90 min
|Improper preservation of large fish results in bacterial degradation of histidine to histamine||Antihistamines (diphenhydramine 25-50 mg IV)
H2 blockers (cimetidine 300 mg IV)
Severe reactions may require subcutaneous epinephrine (0.3-0.5 mL of 1:1000 solution)
|Heavy Metal Poisoning||Source||Symptoms||Treatment|
|Mercury||Ingestion of inorganic mercuric salts||Causes metallic taste, salivation, thirst, discoloration and edema of oral mucous membranes, abdominal pain, vomiting, bloody diarrhea, and acute renal failure||Consult a toxicologist
Remove ingested salts by emesis and lavage, and administer activated charcoal and a cathartic
Dimercaprol is useful in acute ingestion
|Lead||Toxicity results from chronic repeated exposure
It is rare after single ingestion
|Common symptoms include colicky abdominal pain, constipation, headache, and irritability
Diagnosis is based on lead level (>10 mcg/dL)
|Other than activated charcoal and cathartic, severe toxicity should be treated with antidotes (edetate calcium disodium [EDTA] and dimercaprol).|
|Arsenic||Ingestion of pesticide and industrial chemicals||Symptoms usually appear within 1 h after ingestion but may be delayed as long as 12 h
Abdominal pain, watery diarrhea, vomiting, skeletal muscle cramps, profound dehydration, and shock may occur
|Gastric lavage and activated charcoal
Dimercaprol injection 10% solution in oil (3-5 mg/kg IM q4-6h for 2 d) and oral penicillamine (100 mg/kg/d divided qid for 1 wk)