Food Poisoning

Food poisoning is a common, usually mild, but sometimes deadly illness. Typical
symptoms include nausea, vomiting, abdominal cramping, and diarrhea that occur
suddenly (within 48 hours) after consuming a contaminated food or drink.
Depending on the contaminant, fever and chills, bloody stools, dehydration, and
nervous system damage may follow. These symptoms may affect one person or a
group of people who ate the same thing (called an outbreak).

• The Centers for Disease Control and Prevention (CDC) estimates that in the
United States, food poisoning causes about 76 million illnesses, 325,000
hospitalizations, and up to 5,000 deaths each year. One of the most common
bacterial forms of infection, the salmonellae organisms, account for $1
billion in medical costs and lost work time.

• Worldwide, diarrheal illnesses are among the leading causes of death.

Travelers to developing countries often encounter food poisoning in the form
of traveler's diarrhea or "Montezuma’s revenge." Additionally, there are
possible new global threats to the world's food supply through terrorist
actions using food toxins as weapons.

• The known causes of food poisoning can be divided into two categories:
infectious agents and toxic agents.

o Infectious agents include viruses, bacteria, and parasites.

o Toxic agents include poisonous mushrooms, improperly prepared exotic

foods (such as barracuda), or pesticides on fruits and vegetables.

• Food usually becomes contaminated from poor sanitation or preparation.

Food handlers who do not wash their hands after using the bathroom or have
infections themselves often cause contamination. Improperly packaged food
stored at the wrong temperature also promotes contamination.
Food Poisoning Symptoms

Symptoms of food poisoning depend on the type of contaminant and the amount
eaten. The symptoms can develop rapidly, within 30 minutes, or slowly, worsening
over days to weeks. Most of the common contaminants cause nausea, vomiting,
diarrhea, and abdominal cramping. Usually food poisoning is not serious, and the
illness runs its course in 24-48 hours.

Viruses account for most food poisoning cases where a specific contaminant is
found.

• Noroviruses are a group of viruses that cause a mild illness (often termed
"stomach flu") with nausea, vomiting, diarrhea, abdominal pain, headache, and
low-grade fever. These symptoms usually resolve in two to three days. It is
the most common viral cause of adult food poisoning and is transmitted from
water, shellfish, and vegetables contaminated by feces, as well as from
person to person. Outbreaks are more common in densely populated areas
such as nursing homes, schools and cruise ships (hence why the virus is also
known as the "Cruise Ship Illness"). The term norovirus has been approved as
the official name for this group of viruses. Several other names have been
used for noroviruses, including Norwalk-like viruses, caliciviruses (because
they belong to the virus family Caliciviridae), and small round structured
viruses.

• Rotavirus: Causes moderate to severe illness with vomiting followed by

watery diarrhea and fever. It is the most common cause of food poisoning in
infants and children and is transmitted from person to person by fecal
contamination of food and shared play areas.

• Hepatitis A: Causes mild illness with sudden onset of fever, loss of appetite,
and feeling of tiredness followed by jaundice, which is a yellowing of the
eyes and skin. It is transmitted from person to person by fecal
contamination of food.
 Bacteria can cause food poisoning in two different ways. Some bacteria infect the
intestines, causing inflammation and difficulty absorbing nutrients and water,
leading to diarrhea. Other bacteria produce chemicals in foods (known as toxins)
that are poisonous to the human digestive system. When eaten, these chemicals
can lead to nausea and vomiting, kidney failure, and even death.

• Salmonellae: Salmonellae are bacteria that may cause food poisoning; the
illness itself is often referred to as Salmonella or Salmonella infection.
Salmonellae cause a moderate illness with nausea, vomiting, crampy diarrhea,
and headache, which may come back a few weeks later as arthritis (joint
pains). In people with impaired immune systems (such as people with kidney
disease or HIV/AIDS or those receiving chemotherapy for cancer),
Salmonellae can cause a life-threatening illness. The illness is transmitted by
undercooked foods such as eggs, poultry, dairy products, and seafood.

• Campylobacter: Causes mild illness with fever, watery diarrhea, headache,

and muscle aches. Campylobacter is the most commonly identified food-
borne bacterial infection encountered in the world. It is transmitted by raw
poultry, raw milk, and water contaminated by animal feces.

• Staphylococcus aureus: Causes moderate to severe illness with rapid onset

of nausea, severe vomiting, dizziness, and abdominal cramping. These
bacteria produce a toxin in foods such as cream-filled cakes and pies, salads
(most at risk are potato, macaroni, egg, and tuna salads, for example) and
dairy products. Contaminated salads at picnics are common if the food is not
chilled properly.

• Bacillus cereus: Causes mild illness with rapid onset of vomiting, with or
without diarrhea and abdominal cramping. It is associated with rice (mainly
fried rice) and other starchy foods such as pasta or potatoes. It has been
speculated that this bacteria may also be used as a potential terrorist
weapon.
 • Escherichia coli (E coli): Causes moderate to severe illness that begins as
large amounts of watery diarrhea, which then turns into bloody diarrhea.
There are many different types of this bacteria. The worst strain can cause
kidney failure and death (about 3%-5% of all cases). It is transmitted by
eating raw or undercooked hamburger, unpasteurized milk or juices, or
contaminated well water. Outbreaks of food poisoning due to E. coli have also
occurred following ingestion of contaminated produce.

• Shigella (traveler’s diarrhea): Causes moderate to severe illness with fever,

diarrhea containing blood or mucus or both, and the constant urge to have
bowel movements. It is transmitted in water polluted with human wastes.

• Clostridium botulinum (botulism): Causes severe illness affecting the nervous

system. Symptoms start as blurred vision. The person then develops
problems talking and overall weakness. Symptoms then progress to breathing
difficulty and the inability to move arms or legs. Infants and young children
are particularly at risk. It is transmitted in foods such as home-packed
canned goods, honey, sausages, and seafood.

Because botulism can be released in the air, it is considered a potential

biological weapon for terrorists.

• Vibrio cholerae: Causes mild to moderate illness with crampy diarrhea,

headache, nausea, vomiting, and fever with chills. It strikes mostly in the
warmer months of the year and is transmitted by infected, undercooked, or
raw seafood.

Parasites rarely cause food poisoning. When they do, they are usually swallowed in
contaminated or untreated water and cause long-lasting but mild symptoms.

• Giardia (beaver fever): Causes mild illness with watery diarrhea often lasting
one to two weeks. It is transmitted by drinking contaminated water, often
from lakes or streams in cooler mountainous climates.

The infection can also be spread from person to person by food or other
items contaminated with feces from an infected person.
 • Cryptosporidium: Causes moderate illness with large amounts of watery
diarrhea lasting two to four days. May become a long-lasting problem in
people with poor immune systems (such as people with kidney disease or
HIV/AIDS or those on chemotherapy for cancer). It is transmitted by
contaminated drinking water.

Toxic agents are the least common cause of food poisoning. Illness is often an
isolated episode caused by poor food preparation or selection (such as picking wild
mushrooms).

• Mushroom toxins: Illness can range from mild to deadly depending on the
type of mushroom eaten. Often there is nausea, vomiting, and diarrhea.
Some types of mushrooms produce a nerve toxin, which causes sweating,
shaking, hallucinations, and coma.

• Ciguatera poisoning: Caused by eating fish that contains toxins produced by

a marine algae called Gambierdiscus toxicus. It can cause moderate to
severe illness with numbness of the area around the mouth and lips that can
spread to the arms and legs, nausea, vomiting, muscle pain and weakness,
headache, dizziness, and rapid heartbeat. The toxin may cause sensory
problems in which hot things feel cold and cold things feel hot. It is
transmitted by eating certain large game fish from tropical waters-most
specifically barracuda, grouper, snapper, and jacks. According to the CDC,
ciguatera has no cure. Symptoms may disappear in days or weeks, but may
persist for years.

• Scombroid: Causes mild to moderate illness with facial flushing, burning

around the mouth and lips, peppery-taste sensations, a red rash on the upper
body, dizziness, headache, and itchy skin. Severe symptoms may include
blurry vision, respiratory distress, and swelling of the tongue and mouth.
Symptoms typically last from four to six hours, and rarely more than one or
two days. It is transmitted in seafood, mostly mahi-mahi and tuna, but can
also be in Swiss cheese.
 • Pesticides: Cause mild to severe illness with weakness, blurred vision,
headache, cramps, diarrhea, increased production of saliva, and shaking of
the arms and legs. Toxins are transmitted by eating unwashed fruits or
vegetables contaminated with pesticides.

Go to the nearest hospital's emergency department if any of the following

situations occur:

• The ill person passes out or collapse, become dizzy, lightheaded, or have
problems with vision.

• A fever higher than 101°F occurs with the abdominal symptoms.

• Sharp or cramping pains do not go away after 10-15 minutes.

• The ill person's stomach or abdomen swells.

• The skin and/or eyes turn yellow.

• The ill person is vomiting blood or having bloody bowel movements.

• The ill person stops urinating, have decreased urination, or have urine that is
dark in color.

• The ill person develops problems with breathing, speaking, or swallowing.

• One or more joints swell or a rash breaks out on your skin.

• The ill person or caretaker considers the situation to be an emergency.

Medical Care

Because most cases of acute gastroenteritis are self-limited, specific treatment is

not necessary. Some studies have quantified that only 10% of cases require
antibiotic therapy.

• The main objective is adequate rehydration and electrolyte supplementation.

This can be achieved with either an oral rehydration solution (ORS) or
intravenous solutions (eg, isotonic sodium chloride solution, lactated Ringer
solution). Strict personal hygiene should be practiced during the illness.
• Oral rehydration is achieved by administering clear liquids and sodium-
containing and glucose-containing solutions. A simple ORS may be composed
of 1 level teaspoon of salt and 4 heaping teaspoons of sugar added to 1 liter
of water.
• The use of ORS has reduced the mortality rate associated with cholera
from higher than 50% to less than 1%.
• ORS also is indicated in other dehydrating diarrheal diseases.
• ORS promotes cotransport of glucose, sodium, and water across the gut
epithelium, a mechanism unaffected in cholera.
• The World Health Organization (WHO) recommends a solution containing 3.5
g of sodium chloride, 2.5 g of sodium bicarbonate, 1.5 g of potassium
chloride, and 20 g of glucose per liter of water.

Intravenous solutions are indicated in patients who are severely dehydrated or who
have intractable vomiting.
Absorbents (eg, Kaopectate, aluminum hydroxide) help patients have more control
over the timing of defecation. However, they do not alter the course of the
disease or reduce fluid loss.

• An interval of at least 1-2 hours should elapse when using other medications
with absorbents.
• Antisecretory agents, such as bismuth subsalicylate (Pepto-Bismol), may be
useful. The dose is 30 mL every 30 minutes, not to exceed 8-10 doses.
 • Antiperistaltics (opiate derivatives) should not be used in patients with
fever, systemic toxicity, or bloody diarrhea or in patients whose condition
either shows no improvement or deteriorates.
• Diphenoxylate with atropine (Lomotil) is available in tablets (2.5 mg of
diphenoxylate) and liquid (2.5 mg of diphenoxylate/5 mL). The initial dose
for adults is 2 tablets 4 times a day (ie, 20 mg/d). The dose is tapered as
diarrhea improves.
• Loperamide (Imodium) is available over the counter as 2-mg capsules and as a
liquid (1 mg/5 mL). It increases the intestinal absorption of electrolytes and
water and decreases intestinal motility and secretion. The dose in adults is 4
mg initially, followed by 2 mg after each diarrhea stool, not to exceed 16 mg
in a 24-hour period.
• If symptoms persist beyond 3-4 days, the specific etiology should be
determined by performing stool cultures.
• If symptoms persist and the pathogen is isolated, specific treatment should
be initiated.
• Empiric treatment should be initiated in patients with suspected traveler's
diarrhea or dysenteric or systemic symptoms. Treatment with an agent that
covers Shigella and Campylobacter organisms is reasonable in patients with
diarrhea (>4 stools/d) for more than 3 days and with fever, abdominal pain,
vomiting, headache, or myalgias. A 5-day course of a fluoroquinolone (eg,
ciprofloxacin 500 mg PO bid, norfloxacin 400 mg PO bid) is the first-line
therapy.
• TMP/SMX (Bactrim DS 1 tab qd) is an alternative therapy, but resistant
organisms are common in the tropics. Infection with either V cholerae or V
parahaemolyticus can be treated either with a fluoroquinolone or with
doxycycline (100 mg PO bid).
• In the absence of dysentery, do not administer antibiotics until a
microbiologic diagnosis is confirmed and E coli O157:H7 is ruled out.

Rehydration solutions

The main objective is adequate rehydration and electrolyte supplementation. This

can be achieved with ORS or intravenous solutions (eg, isotonic sodium chloride
solution, lactated Ringer solution).
Lactated Ringer solution with NS

Both fluids are essentially isotonic and have equivalent volume-restorative

properties. While some differences exist between metabolic changes observed
with administration of large quantities of either fluid, for practical purposes and in
most situations, differences are clinically irrelevant. No demonstrable difference
exists in hemodynamic effect, morbidity, or mortality between resuscitation using
either NS

Oral electrolyte mixtures (Rehydralyte, Pedialyte)

Acts by glucose-facilitated absorption of sodium and water, which is unaffected in

diseases such as cholera. Oral rehydration is achieved using clear liquids and
sodium-containing and glucose-containing solutions. WHO recommends a solution
containing 3.5 g of sodium chloride, 2.5 g sodium bicarbonate, 1.5 g potassium
chloride, and 20 g glucose per liter of water.
A simple solution may be made using 1 level tsp salt and 4 heaping tsp sugar added
to 1 L water.

Antidiarrheals

Adsorbents (eg, attapulgite, aluminum hydroxide) help patients have more control
over the timing of defecation but do not alter the course of the disease or reduce
fluid loss. Antisecretory agents (eg, bismuth subsalicylate) may be useful.
Antiperistaltics (opiate derivatives) should not be used in patients with fever,
systemic toxicity, bloody diarrhea, or in patients whose condition either shows no
improvement or deteriorates.

Attapulgite (Kaopectate, Diasorb)

Adsorbent and protectant that controls diarrhea.

Aluminum hydroxide (Amphojel, Dialume, ALternaGEL)

Commonly used as an antacid. Adsorbent and protectant that controls diarrhea.

Bismuth subsalicylate (Pepto-Bismol)

Antisecretory agent that also may have antimicrobial and anti-inflammatory

effects.

Diphenoxylate and atropine (Lomotil, Lonox)

Drug combination that consists of diphenoxylate, which is a constipating

meperidine congener, and atropine to discourage abuse. Inhibits excessive GI
propulsion and motility.
Available in tabs (2.5 mg diphenoxylate) and liquid (2.5 mg diphenoxylate/5 mL).

Loperamide (Imodium)

Acts on intestinal muscles to inhibit peristalsis and slow intestinal motility.

Prolongs movement of electrolytes and fluid through bowel and increases viscosity
and loss of fluids and electrolytes.
Available over the counter in 2-mg capsules and liquid (1 mg/5 mL).

• Dosing
• Interactions
• Contraindications
• Precautions

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely
pathogens in the context of the clinical setting. Antibiotic selection should be
guided by blood culture sensitivity.

iprofloxacin (Cipro)

First-line therapy. Fluoroquinolone with activity against pseudomonads,

streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative
organisms, but no activity against anaerobes. Inhibits bacterial DNA synthesis,
and, consequently, growth.
Norfloxacin (Noroxin)

Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, S

epidermidis, and most gram-negative organisms, but no activity against anaerobes.
Inhibits bacterial DNA synthesis, and, consequently, growth.

Trimethoprim and sulfamethoxazole (Bactrim DS, Septra DS)

Alternative therapy, but resistant organisms are common in the tropics. Inhibits
bacterial growth by inhibiting synthesis of dihydrofolic acid.

Doxycycline (Doryx, Vibramycin, Vibra-Tabs)

For V cholerae or V parahaemolyticus infections. Inhibits protein synthesis and

thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of
susceptible bacteria.

Rifaximin (Xifaxan, RedActiv, Flonorm)

Nonabsorbed (<0.4%), broad-spectrum antibiotic specific for enteric pathogens of

the gastrointestinal tract (ie, gram-positive, gram-negative, aerobic, anaerobic).
Rifampin structural analog. Binds to beta-subunit of bacterial DNA-dependent RNA
polymerase, thereby inhibiting RNA synthesis. Indicated for E coli
(enterotoxigenic and enteroaggregative strains) associated with travelers'
diarrhea.

Prevention

• Food poisoning caused by infectious agents is prevented by the following:

o Strict personal hygiene
o Adequate cooking
o Avoidance of cross-contamination of raw and cooked foods
o Keeping food at appropriate temperatures (ie, <40°F for refrigerated
items and >140°F for hot items)
• Proper maintenance of vending machines and avoidance of acidic beverages in
metallic containers prevent heavy metal poisoning.
 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 is found in the well-controlled clinical
trials involving irradiated food.