Editorial: Foodborne Illness More Common Than Appreciated

The recent Escherichia coli outbreak in Germany reminds us yet again about the threat of foodborne illness and the need for awareness about the clinical manifestations, the treatment, and the public health implications.

On June 14, a 2-year-old boy became the first child and the 37th person to die in Germany’s ongoing E. coli outbreak. Here in the United States, the Centers for Disease Control and Prevention estimates 48 million people – one in every six Americans – become ill, 128,000 are hospitalized, and 3,000 die of foodborne illness annually. About half of all foodborne illness occurs in children, who are particularly vulnerable due to their immature immune systems, lower body weight, and reduced stomach acid production.

Norovirus has become the most common recognized foodborne pathogen, causing about 5 million illnesses a year, followed by nontyphoidal Salmonella, with just over 1 million annual cases, and Clostridium perfringens, at just under 1 million, according to the CDC. Norovirus illness is usually mild, but it did cause an estimated 149 annual deaths. Nontyphoidal Salmonella is the most common serious cause of foodborne illness with an estimated 378 annual deaths, followed by Toxoplasma gondii (327 deaths) and Listeria monocytogenes (255 deaths). More information on the epidemiology and incidence of foodborne disease in 2011 can be found on the CDC website.

The following foodborne illnesses are frequent causes of morbidity in children. Information on the possible foodborne sources and the effects of infection are from a report compiled by the Pew Health Group in collaboration with the Center for Foodborne Illness Research and Prevention.

• Salmonella. These infections occur in approximately 75 children/100,000 under age 4 years, according to the CDC. It is commonly associated with foods of animal origin, including beef, poultry, milk, and eggs, or cross-contamination from these with other foods. Typical symptoms include diarrhea, fever, and abdominal cramps. More serious short-term manifestations can include colitis, meningitis, septicemia, and death. Treatment involves rehydration as needed.

In general, antibiotic therapy is not warranted, but in immunocompromised hosts and children younger than age 6 months, antimicrobial therapy may be beneficial. In such settings, ceftriaxone is effective when susceptible, specifically in high-risk populations.

• Shigella. This infection occurs in about 28/100,000 children under age 4 years and 26/100,000 for those aged 4-11 years, according to the CDC. It is often associated with vegetables harvested in fields contaminated with sewage; flies that breed in infected feces and contaminate the food; and drinking, swimming, or playing in contaminated water. Short-term effects include high fever, diarrhea that is often bloody, stomach cramps, and seizures in children less than age 2 years. Reactive or chronic arthritis can be a postinfectious sequelae.

Treatment includes rehydration as necessary, and antibiotics for severe disease or dysentery, particularly in those with underlying immunosuppression. Ceftriaxone and ciprofloxacin are effective, although the latter is not licensed for use in young children. Resistance to amoxicillin and trimethoprim-sulfamethoxazole (TMP-SMZ) is common. Treatment of mild cases may be indicated to shorten the duration of excretion.

• Campylobacter. This infection affects 29/100,000 children under age 4 years, similar in incidence to Shigella. Foodborne sources included raw or undercooked poultry or foods cross-contaminated by poultry, unpasteurized milk, and contaminated water. Symptoms include diarrhea (sometimes bloody), cramping, abdominal pain, urinary tract infection, fever, and meningitis. Campylobacter is also associated with Guillain-Barré syndrome or reactive/chronic arthritis.

Again, treatment involves rehydration as necessary. Macrolides (azithromycin or erythromycin) can shorten duration of illness and prevent relapse. These are most effective when given early in the course of infection.

• E. coli or other shiga toxin–producing strains. This foodborne infection has been in the headlines lately, affects about 4/100,000 children between 4 and 11 years of age. Typical food sources include ground beef and other meats, green leafy vegetables, unpasteurized juices or raw milk, or soft cheeses made from raw milk. Symptoms include severe stomach cramps, diarrhea (often bloody), and vomiting. Hemolytic-uremic syndrome occurs in about 15% of children with E. coli 0157:H7 infection. This can result in long-term kidney damage as well as death.

In general, antibiotics have not been shown to benefit patients. Early reports of increased risk of hemolytic-uremic syndrome with antibiotic treatment have not been confirmed. As with the others, rehydration and supportive therapy are the mainstays of treatment.

• Listeria. This infection occurs in about 0.76/100,000 children under age 4 years, according to the CDC. About one-third of all cases involve pregnant women. Common food sources include uncooked meats, particularly cold cuts and hot dogs, as well as smoked seafood, raw milk, soft cheeses made from raw milk, and vegetables grown in contaminated soil or fertilizer. Symptoms include fever, muscle aches, nausea, and diarrhea. Headaches, stiff neck, confusion, loss of balance, and seizures can result if infection spreads to the nervous system.

For invasive disease, ampicillin plus an aminoglycoside is recommended. For penicillin-allergic patients, TMP-SMZ or high-dose vancomycin can be used. Cephalosporins are generally inactive. In the majority of patients with febrile gastroenteritis, the illness is self-limited (typical duration, 2 days or less) and therefore, generally no antibiotic treatment is necessary.

In pregnant women, listerial febrile gastroenteritis can lead to fetal death, premature birth, or infected newborns. Oral ampicillin or TMP-SMZ can be given for several days in immunocompromised or pregnant patients with listerial febrile gastroenteritis, particularly if they are still symptomatic once the culture result is known.

Dr. Pelton is chief of pediatric infectious disease and also is the coordinator of the maternal-child HIV program at Boston Medical Center. He said he had no relevant financial disclosures. E-mail Dr. Pelton at [email protected].

This column, ID Consult, appears regularly in Pediatric News, a publication of Elsevier.

The recent Escherichia coli outbreak in Germany reminds us yet again about the threat of foodborne illness and the need for awareness about the clinical manifestations, the treatment, and the public health implications.

On June 14, a 2-year-old boy became the first child and the 37th person to die in Germany’s ongoing E. coli outbreak. Here in the United States, the Centers for Disease Control and Prevention estimates 48 million people – one in every six Americans – become ill, 128,000 are hospitalized, and 3,000 die of foodborne illness annually. About half of all foodborne illness occurs in children, who are particularly vulnerable due to their immature immune systems, lower body weight, and reduced stomach acid production.

Norovirus has become the most common recognized foodborne pathogen, causing about 5 million illnesses a year, followed by nontyphoidal Salmonella, with just over 1 million annual cases, and Clostridium perfringens, at just under 1 million, according to the CDC. Norovirus illness is usually mild, but it did cause an estimated 149 annual deaths. Nontyphoidal Salmonella is the most common serious cause of foodborne illness with an estimated 378 annual deaths, followed by Toxoplasma gondii (327 deaths) and Listeria monocytogenes (255 deaths). More information on the epidemiology and incidence of foodborne disease in 2011 can be found on the CDC website.

The following foodborne illnesses are frequent causes of morbidity in children. Information on the possible foodborne sources and the effects of infection are from a report compiled by the Pew Health Group in collaboration with the Center for Foodborne Illness Research and Prevention.

• Salmonella. These infections occur in approximately 75 children/100,000 under age 4 years, according to the CDC. It is commonly associated with foods of animal origin, including beef, poultry, milk, and eggs, or cross-contamination from these with other foods. Typical symptoms include diarrhea, fever, and abdominal cramps. More serious short-term manifestations can include colitis, meningitis, septicemia, and death. Treatment involves rehydration as needed.

In general, antibiotic therapy is not warranted, but in immunocompromised hosts and children younger than age 6 months, antimicrobial therapy may be beneficial. In such settings, ceftriaxone is effective when susceptible, specifically in high-risk populations.

• Shigella. This infection occurs in about 28/100,000 children under age 4 years and 26/100,000 for those aged 4-11 years, according to the CDC. It is often associated with vegetables harvested in fields contaminated with sewage; flies that breed in infected feces and contaminate the food; and drinking, swimming, or playing in contaminated water. Short-term effects include high fever, diarrhea that is often bloody, stomach cramps, and seizures in children less than age 2 years. Reactive or chronic arthritis can be a postinfectious sequelae.

Treatment includes rehydration as necessary, and antibiotics for severe disease or dysentery, particularly in those with underlying immunosuppression. Ceftriaxone and ciprofloxacin are effective, although the latter is not licensed for use in young children. Resistance to amoxicillin and trimethoprim-sulfamethoxazole (TMP-SMZ) is common. Treatment of mild cases may be indicated to shorten the duration of excretion.

• Campylobacter. This infection affects 29/100,000 children under age 4 years, similar in incidence to Shigella. Foodborne sources included raw or undercooked poultry or foods cross-contaminated by poultry, unpasteurized milk, and contaminated water. Symptoms include diarrhea (sometimes bloody), cramping, abdominal pain, urinary tract infection, fever, and meningitis. Campylobacter is also associated with Guillain-Barré syndrome or reactive/chronic arthritis.

Again, treatment involves rehydration as necessary. Macrolides (azithromycin or erythromycin) can shorten duration of illness and prevent relapse. These are most effective when given early in the course of infection.

• E. coli or other shiga toxin–producing strains. This foodborne infection has been in the headlines lately, affects about 4/100,000 children between 4 and 11 years of age. Typical food sources include ground beef and other meats, green leafy vegetables, unpasteurized juices or raw milk, or soft cheeses made from raw milk. Symptoms include severe stomach cramps, diarrhea (often bloody), and vomiting. Hemolytic-uremic syndrome occurs in about 15% of children with E. coli 0157:H7 infection. This can result in long-term kidney damage as well as death.

In general, antibiotics have not been shown to benefit patients. Early reports of increased risk of hemolytic-uremic syndrome with antibiotic treatment have not been confirmed. As with the others, rehydration and supportive therapy are the mainstays of treatment.

• Listeria. This infection occurs in about 0.76/100,000 children under age 4 years, according to the CDC. About one-third of all cases involve pregnant women. Common food sources include uncooked meats, particularly cold cuts and hot dogs, as well as smoked seafood, raw milk, soft cheeses made from raw milk, and vegetables grown in contaminated soil or fertilizer. Symptoms include fever, muscle aches, nausea, and diarrhea. Headaches, stiff neck, confusion, loss of balance, and seizures can result if infection spreads to the nervous system.

For invasive disease, ampicillin plus an aminoglycoside is recommended. For penicillin-allergic patients, TMP-SMZ or high-dose vancomycin can be used. Cephalosporins are generally inactive. In the majority of patients with febrile gastroenteritis, the illness is self-limited (typical duration, 2 days or less) and therefore, generally no antibiotic treatment is necessary.

In pregnant women, listerial febrile gastroenteritis can lead to fetal death, premature birth, or infected newborns. Oral ampicillin or TMP-SMZ can be given for several days in immunocompromised or pregnant patients with listerial febrile gastroenteritis, particularly if they are still symptomatic once the culture result is known.

Dr. Pelton is chief of pediatric infectious disease and also is the coordinator of the maternal-child HIV program at Boston Medical Center. He said he had no relevant financial disclosures. E-mail Dr. Pelton at [email protected].

This column, ID Consult, appears regularly in Pediatric News, a publication of Elsevier.

The recent Escherichia coli outbreak in Germany reminds us yet again about the threat of foodborne illness and the need for awareness about the clinical manifestations, the treatment, and the public health implications.

On June 14, a 2-year-old boy became the first child and the 37th person to die in Germany’s ongoing E. coli outbreak. Here in the United States, the Centers for Disease Control and Prevention estimates 48 million people – one in every six Americans – become ill, 128,000 are hospitalized, and 3,000 die of foodborne illness annually. About half of all foodborne illness occurs in children, who are particularly vulnerable due to their immature immune systems, lower body weight, and reduced stomach acid production.

Norovirus has become the most common recognized foodborne pathogen, causing about 5 million illnesses a year, followed by nontyphoidal Salmonella, with just over 1 million annual cases, and Clostridium perfringens, at just under 1 million, according to the CDC. Norovirus illness is usually mild, but it did cause an estimated 149 annual deaths. Nontyphoidal Salmonella is the most common serious cause of foodborne illness with an estimated 378 annual deaths, followed by Toxoplasma gondii (327 deaths) and Listeria monocytogenes (255 deaths). More information on the epidemiology and incidence of foodborne disease in 2011 can be found on the CDC website.

The following foodborne illnesses are frequent causes of morbidity in children. Information on the possible foodborne sources and the effects of infection are from a report compiled by the Pew Health Group in collaboration with the Center for Foodborne Illness Research and Prevention.

• Salmonella. These infections occur in approximately 75 children/100,000 under age 4 years, according to the CDC. It is commonly associated with foods of animal origin, including beef, poultry, milk, and eggs, or cross-contamination from these with other foods. Typical symptoms include diarrhea, fever, and abdominal cramps. More serious short-term manifestations can include colitis, meningitis, septicemia, and death. Treatment involves rehydration as needed.

In general, antibiotic therapy is not warranted, but in immunocompromised hosts and children younger than age 6 months, antimicrobial therapy may be beneficial. In such settings, ceftriaxone is effective when susceptible, specifically in high-risk populations.

• Shigella. This infection occurs in about 28/100,000 children under age 4 years and 26/100,000 for those aged 4-11 years, according to the CDC. It is often associated with vegetables harvested in fields contaminated with sewage; flies that breed in infected feces and contaminate the food; and drinking, swimming, or playing in contaminated water. Short-term effects include high fever, diarrhea that is often bloody, stomach cramps, and seizures in children less than age 2 years. Reactive or chronic arthritis can be a postinfectious sequelae.

Treatment includes rehydration as necessary, and antibiotics for severe disease or dysentery, particularly in those with underlying immunosuppression. Ceftriaxone and ciprofloxacin are effective, although the latter is not licensed for use in young children. Resistance to amoxicillin and trimethoprim-sulfamethoxazole (TMP-SMZ) is common. Treatment of mild cases may be indicated to shorten the duration of excretion.

• Campylobacter. This infection affects 29/100,000 children under age 4 years, similar in incidence to Shigella. Foodborne sources included raw or undercooked poultry or foods cross-contaminated by poultry, unpasteurized milk, and contaminated water. Symptoms include diarrhea (sometimes bloody), cramping, abdominal pain, urinary tract infection, fever, and meningitis. Campylobacter is also associated with Guillain-Barré syndrome or reactive/chronic arthritis.

Again, treatment involves rehydration as necessary. Macrolides (azithromycin or erythromycin) can shorten duration of illness and prevent relapse. These are most effective when given early in the course of infection.

• E. coli or other shiga toxin–producing strains. This foodborne infection has been in the headlines lately, affects about 4/100,000 children between 4 and 11 years of age. Typical food sources include ground beef and other meats, green leafy vegetables, unpasteurized juices or raw milk, or soft cheeses made from raw milk. Symptoms include severe stomach cramps, diarrhea (often bloody), and vomiting. Hemolytic-uremic syndrome occurs in about 15% of children with E. coli 0157:H7 infection. This can result in long-term kidney damage as well as death.

In general, antibiotics have not been shown to benefit patients. Early reports of increased risk of hemolytic-uremic syndrome with antibiotic treatment have not been confirmed. As with the others, rehydration and supportive therapy are the mainstays of treatment.

• Listeria. This infection occurs in about 0.76/100,000 children under age 4 years, according to the CDC. About one-third of all cases involve pregnant women. Common food sources include uncooked meats, particularly cold cuts and hot dogs, as well as smoked seafood, raw milk, soft cheeses made from raw milk, and vegetables grown in contaminated soil or fertilizer. Symptoms include fever, muscle aches, nausea, and diarrhea. Headaches, stiff neck, confusion, loss of balance, and seizures can result if infection spreads to the nervous system.

For invasive disease, ampicillin plus an aminoglycoside is recommended. For penicillin-allergic patients, TMP-SMZ or high-dose vancomycin can be used. Cephalosporins are generally inactive. In the majority of patients with febrile gastroenteritis, the illness is self-limited (typical duration, 2 days or less) and therefore, generally no antibiotic treatment is necessary.

In pregnant women, listerial febrile gastroenteritis can lead to fetal death, premature birth, or infected newborns. Oral ampicillin or TMP-SMZ can be given for several days in immunocompromised or pregnant patients with listerial febrile gastroenteritis, particularly if they are still symptomatic once the culture result is known.

Dr. Pelton is chief of pediatric infectious disease and also is the coordinator of the maternal-child HIV program at Boston Medical Center. He said he had no relevant financial disclosures. E-mail Dr. Pelton at [email protected].

This column, ID Consult, appears regularly in Pediatric News, a publication of Elsevier.