Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Thomas Miller MD
Case #1
Jack called from San Francisco at 7:30
pm.
Dad I am leaving for Indonesia in 2
days. Do I need any shots before I
go. What about Malaria prevention?
Topics of Discussion
Risk assessment
Risk reduction
Shared decisions
Resources
www.cdc.gov/travel
Travax
Yellow book
Risk assessment
Medical history
Chronic illnesses
Immune status
Vaccination history
Travel itinerary
Destination
Style of travel
Duration
Planned activities
Medical history
Healthy 24 year old
Complete childhood immunizations
Hepatitis A and B vaccines given in
school
Before college
Meningococcus
Updated MMR
Destination: Indonesia
Bali and Mentawai Islands
Routine
Hepatitis A
Hepatitis B
Typhoid
Rabies
Japanese encephalitis
Malaria prevention
Other considerations
Style of travel
Hostel style
Not airconditioned
Not usual tourist destination
Duration 1 month
Planned activities
Travelers Diarrhea
Epidemiology
Most common illness in travelers to resource
poor areas
90% of travelers will make an error in what
they eat or drink within several days
50% of travelers will experience illness over
the course of a 2-3 week vacation
The illness
>2 loose stools over 24 hrs
Fever, nausea, vomiting, cramping
Duration 3-5 days
Cause
Bacteriologic enteropathogens 90%
Enterotoxigenic E. Coli
Others: Camphylobacter, Salmonella, Shigella
Prevention
Standard food safety measures
Boil it; cook it; peel it or forget it.
Bottled beverages
Restaurant hygiene a bigger factor
Chemoprophylaxis
Peptobismol: 2 tabs qid
Fluoroquinolones Ciprofloxacin 500mg qd
Infection rates reduced from 50% to 5%
Special Populations
VIPs
Vulnerable hosts
Immune incompetent
HIV, transplant, chemotherapy
Treatment
Loperamide (imodium): antisecretory
Fluoroquinolones
Ciprofloxacin 500bid x 1 day
Can be extended for 3 days if needed
Shortens the course of illness by 1.5 days
Improvement noted with 6-12hr
Oral rehydration
Sodas and broth
Oral rehydration therapy
Rifaximin
New nonabsorbable antibiotic
A rifamycin
Broad spectrum of activity against gram
pos. and neg. organisms
Approved for the treatment of
uncomplicated travelers diarrhea
Little effect on gut flora
Prophylactic use
Dose: 200mg qd
75% effective
Disadvantages
Not effective for invasive disease dysentery
Fever
Systemic toxicity
Bloody diarrhea
Cost $3.80/pill
Background
Enterotoxigenic E coli causes most TD
Heat-labile enterotoxin (LT) is found in 2/3 of
ETEC
Natural immunity to LT occurs and provides
protection
Oral cholera vaccine cross reacts with LT and
protects against TD
LT is strongly antigenic
My patient
Standard precautions
Not a VIP
No chronic diseases
Loperamide
Ciprofloxacin 500 bid x 3 days max
Immunizations
Routine
Hepatitis A
Hepatitis B
Typhoid
Rabies
Japanese encephalitis
Typhoid Vaccine
Typhoid fever
Caused by Salmonella enterica
Source: contaminated food or water
Risk in South Asia highest
Fever, headache, malaise, not diarrhea
400 cases per year in US travelers
Second most common cause of fever in
return travelers
Single dose
Complete 2 weeks prior to exposure
Local erythema and indration rarely
Boost at 2 years
$30-40
My patient
Leaves in 2 days, but stays for a month
Refrigeration
$$$ and convenience
Rabies
Dont pet the dogs
Time is on our side
Japanese Encephalitis
Malaria Prevention
Malaria
Fever, headache, back pain, myalgias
1500 cases per year reported to CDC
Can be fatal
60%
14%
13%
.03%
Prevention
Avoidance
Chemoprophylaxis
Avoidance
Limit night time outings
Clothing: long sleeves and pants
Screened or air conditioned rooms
Mosquito netting
Permethrin coated clothes
30% DEET effective for 4-8 hours
Results
DEET superior to all other products
Higher concentrations provided longer
protection
24% solution protected for 300 min
Controlled release formulation was no better
20% Picaridin
Now available in US
As effective as Deet
No odor
Not a solvent
Chemoprophylaxis
Best tolerated
Daily dosing and continued for 1 week after return
Expensive - $300 for 30 day trip
Doxycycline 100mg qd
Mefloquine
Primaquine
Our patient
Considers cost and risk of solar
sensitization
Doxycycline and sunscreen
Resistant TD
Reported first in Thailand, but now
spreading throughout SE Asia
Among military personnel in Thailand
Camphylobacter causes 20-60% of TD
85% are resistant to fluoroquinolone
Pathogens
Outcomes
72 hour cure rate
Azithromycin 1gm
Azithromycin 500mg bid
Levofloxacin 500mg qd
94%
80%
70%
TLUS
Azithromycin 1gm
Azithromycin 500mg bid
Levofloxacin 500mg qd
39hr
43hr
56hr
Side effects
Nausea after first dose
Azithromycin 1gm
14%
6%
2%
17%
8%
6%
Clear fluids
Sodas and broth
Oral rehydration solution
Happy Campers
Doxycycline photosensitivity
Painful erythematous eruption
Mechanism poorly understood
Prevented by sunscreen
Altitude Sickness
Clinical Presentations
25% of people at alt>8,000 ft. Feels like hangover (HA, nausea). Develops
2-12 hrs after arrival, resolves after 24-72 hrs of acclimatization
Treatments
Dose: 125 mg po bid starting one day prior to ascent and continued for 2
Dexamethesone: