By Laurence Degelsmith, MD
November 16, 2007
It’s turkey time again. Thanksgiving is a time for families to gather. It’s also a time for all of us to stuff our faces, right after stuffing the turkey. Hopefully, we will all keep that food in our stomachs where it belongs and not fall victim to a food borne illness such as Salmonella.
There are many organisms that can cause us to lose our turkey. Salmonella is one of the most well known, but viruses are actually more likely to cause gastroenteritis than bacterial agents.
The most common bacterial agents include Salmonella, Shigella, Campylobacter, E. Coli, Yersinia, Vibrio, Bacillus cereus, Staph aureus, Clostridium difficile, Clostridium botulinum, Listeria and a few others. There are also parasites such as Entamoeba histolytica and Giardia which are less common, but do cause uncomfortable intestinal infections. They are sometimes hard to diagnose because they are not as common. Today I will just focus on the bacteria listed above that cause food borne illnesses you will wish to avoid giving your guests during the approaching holiday.
Just make sure to cook the turkey well in order to prevent the arrival of that uninvited dinner guest, Sal. That is, Sal Minella. Avoiding some of the other food borne toxins and bacterial infections is sometimes just a matter of luck.
Most common bacterial agents likely to make your guests lose their lunch
Salmonella and campylobacter are the two most common bacterial pathogens identified in acute intestinal illnesses. These are followed closely by shigella and then occasionally E. coli 0157:H7 and rarely Clostridium botulinum (botulism). Vibrio (obtained by eating contaminated raw shellfish), yersinia and listeria are much less commonly identified. Pathogens such as other strains of E. coli and Staph aureus are quite common but are not usually identified since they produce toxins that cause illness but the bacteria are not readily detectable by stool culture.
These bacteria either directly invade the intestinal lining or produce toxins that irritate the intestinal lining, which causes diarrhea and usually abdominal pain. Several of the bacteria can cause bloody diarrhea with pus and mucus while others cause cramping and watery diarrhea. Vomiting is often present and fevers are also common in most infections but not all. Two people infected with the same bacteria can have slightly different symptoms depending on individual factors including the immune system. It is also common for one person to have symptoms for only a day or two while a family member might remain ill for several days from the same organism.
Salmonella and campylobacter are often associated with undercooked poultry among other food items. Salmonella is also associated with certain reptiles including snakes, turtles or lizards which many children have as pets. It is recommended that children under the age of 5 not come in contact with these animals due to the risk of contracting Salmonella.
More serious illnesses than gastroenteritis
A few organisms can cause a more serious illness than gastroenteritis. E. coli 0157:H7, which we hear about on the news, is known to cause outbreaks of severe gastrointestinal illness with abdominal pain, bloody diarrhea and occasionally kidney disease, especially in children. This kidney ailment, called hemolytic uremic syndrome, can shut down the kidneys, necessitating temporary dialysis, and can occasionally be fatal, again most often in children. E. coli 0157:H7 is often found in beef products and has been found in certain raw vegetables.
Clostridium botulinum causes botulism, and is often associated with improperly canned or bottled foods. This bacteria can cause neurological symptoms, and in extreme cases temporary paralysis which sometimes requires a ventilator to support breathing. Every so often we hear about an infant contracting infant botulism from honey. Infants should never be fed honey since it may contain botulinum spores which can cause botulism. Symptoms include lethargy, poor feeding, weakness, limp appearance, droopy eyes and a weak cry. Infants have weak immune systems which puts them at risk for developing this disease.
Fish courses have their own dangers
Certain toxins found in fish such as tuna and mackerel when they are not frozen properly after being caught can cause other neurological (but non-fatal) symptoms such as itching, numbness and a reversal of hot and cold sensation on one’s skin (something hot touching your skin might feel cold and visa versa). These symptoms are associated with scombroid fish poisoning and ciguatera poisoning. Unfortunately, the toxin, which is simply histamine, is not destroyed by cooking. Several years ago the emergency department where I was working was inundated with multiple patients who all had one thing in common: they ate the boiled tuna cafeteria special. We had ten patients with vomiting, itching, generalized skin redness and diarrhea. The offending tuna was laced with histamine, which had caused scombroid fish poisoning. It was easily treated with antihistamines (Benadryl) and antiemetics (compazine). Everyone responded well to the same treatment and went home with a distaste for tuna.
Recipe for recovery: Just add water, plus . . .
I could go on and on about other specific organisms and the symptoms they are associated with but I would prefer to get to a more important topic: treatment. Rehydration is the mainstay of treatment. Oral hydration with an over the counter electrolyte solution like Gatorade or Pedialyte is preferable to intravenous fluid if tolerated, but most patients presenting to the emergency department get intravenous hydration since it’s faster and guaranteed not to be lost due to vomiting. Antidiarrheals such as Imodium or Kaopectate are acceptable in cases of non-bloody diarrhea and non-inflammatory diarrhea. Infections with bloody diarrhea caused by shigella bacteria, E. coli 0157:H7 or Salmonella may worsen when antidiarrheals are used. Antidiarrheals are also contraindicated for inflammatory diseases with bloody diarrhea such as ulcerative colitis and Crohn’s disease due to an increased risk of developing an intestinal obstruction.
The great neutralizer: Pepto Bismol
Pepto Bismol is a medication I recommend in almost every case of diarrhea with or without vomiting since it can help decrease the amount of stools per day and also relieve some of the cramping.Two tablets or two tablespoons taken four times daily will often alleviate many of the symptoms. Remember, Pepto Bismol has aspirin in it so don’t take it if you can’t take aspirin. Pepto Bismol can be taken for many days since very little of the medication is absorbed into the body from the gastrointestinal tract but it may turn your tongue or your stool temporarily black.
Use of antibiotics for treatment
Antibiotics are sometimes used to treat certain food borne infections. Traveler’s diarrhea (Montezuma’s revenge) caused by the E. coli toxin (not the strain 0157:H7) can be effectively treated with antibiotics, which potentially cuts the duration of illness in half. Salmonella is usually not treated with antibiotics unless the patient is a very young child or infant, immune compromised or has an artificial heart valve. Antibiotics, especially Cipro, are generally avoided because they can prolong the illness, which is usually not a serious infection in healthy adults. Infections of E. coli 0157:H7 are usually not treated with antibiotics because they can increase the risk of developing hemolytic uremic syndrome. Most other community-acquired gastrointestinal illnesses associated with fever and bloody diarrhea are commonly treated with an antibiotic such as a fluoroquinolone (Cipro) or Bactrim. Intestinal illnesses that develop within 12 hours of eating a suspect food item are usually due to Staph bacteria and are not treated with antibiotics. The decision to give antibiotics is sometimes made if a particular organism is suspected based on the timing of symptoms in relation to what was eaten and when it was eaten. Most of the serious pathogens including shigella, salmonella, campylobacter and E. coli 0157:H7 require a two to three day incubation period and therefore don’t cause symptoms right away after eating the offending food item.
Keeping guests healthy, in a nutshell
In summary, most food borne infections are self-limiting and resolve in one - two days at most. Pepto Bismol is usually helpful no matter what the cause is and antidiarrheals for non-bloody diarrheal infections can be helpful, especially if profuse watery diarrhea is beginning to cause dehydration. Gatorade, Pedialyte or water with salty crackers is recommended to prevent dehydration and to retain the body’s electrolytes (sodium and potassium). Medicines for vomiting are also available but usually require a prescription or a visit to the emergency department. A medical evaluation should be sought if there is bloody diarrhea, fever, significant abdominal pain, dehydration or if symptoms last for longer than two days. Symptoms of dehydration include weakness, decreased urine output, lightheadedness or just feeling blah. In children with intestinal illnesses, a BRAT diet (bananas, rice, applesauce and toast) and avoidance of milk products (due to transient lactase deficiency) has been advocated for years by many pediatricians but there is little supporting data to show that this diet is any better than other simple foods.
Author’s note: This article encompasses general guidelines taken from several published sources as well as my ten years of personal experience as an emergency physician. There will often be exceptions to the above guidelines because the risk vs. benefit ratio of using any medication will be different for each patient.
Laurence Degelsmith graduated from Horace Greeley High School in 1985, has an undergraduate degree from Washington University in Saint Louis, attended New York Medical College and did his residency in emergency medicine at the University of Michigan. He is an emergency department physician at Northern Westchester Hospital in Mt. Kisco and a member of the Chappaqua Volunteer Ambulance Corps.
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