Bacterial Enteric Infections
Prevention of Exposure
Food
Health-care providers should advise HIV-infected persons not to eat raw
or under-cooked eggs (including foods that may contain raw eggs [e.g., some
preparations of hollandaise sauce, Caesar and other salad dressings, and
mayonnaise]); raw or under-cooked poultry, meat, or seafood; or unpasteurized
dairy products. Poultry and meat should be well cooked and should not be
pink in the middle (internal temperature >165 F [73.8 C]). Produce should
be washed thoroughly before being eaten.
Health-care providers should advise HIV-infected persons to avoid cross-contamination of foods. For example, uncooked meats should not come into contact with other foods, and hands, cutting boards, counters, and knives and other utensils should be washed thoroughly after contact with uncooked foods (BIII).
Health-care providers should advise HIV-infected persons that, although the incidence of listeriosis is low, it is a serious disease that occurs with unusually high frequency among HIV-infected persons who are severely immunosuppressed. Such persons may choose to avoid soft cheeses because some studies have shown an association between these foods and listeriosis. These studies also have documented an association between ready-to-eat foods (e.g., hot dogs and cold cuts from delicatessen counters) and listeriosis. An immunosuppressed, HIV-infected person who wishes to reduce the risk of foodborne disease as much as possible may choose to reheat such foods until they are steaming hot before eating them.
Pets
When obtaining a new pet, HIV-infected persons should avoid young animals
(aged <6 months), especially those that have diarrhea.
HIV-infected persons should avoid contact with animals that have diarrhea (BIII). HIV-infected pet owners should seek veterinary care for animals with diarrheal illness, and a fecal sample from such animals should be examined for Cryptosporidium, Salmonella, and Campylobacter.
HIV-infected persons should wash their hands after handling pets (especially before eating) and should avoid contact with pets' feces.
HIV-infected persons should avoid contact with reptiles (e.g., snakes, lizards, iguanas, and turtles) because of the risk of salmonellosis.
Travel
The risk of food- and waterborne infections among immunosuppressed,
HIV-infected persons is magnified during travel to developing countries.
Those who elect to travel to such countries should avoid foods and beverages
that may be contaminated, particularly raw fruits and vegetables, raw or
undercooked seafood or meat, tap water, ice made with tap water, unpasteurized
milk and dairy products, and items sold by street vendors (AII). Foods and
beverages that are generally safe include steaming-hot foods, fruits that
are peeled by the traveler, bottled (especially carbonated) beverages, hot
coffee and tea, beer, wine, and water brought to a rolling boil for 1 minute. Treatment of water with iodine or chlorine may not be as effective
as boiling but can be used when boiling is not practical.
Prevention of Disease
Prophylactic antimicrobial agents are not generally recommended for travelers. The effectiveness of these agents depends on local
antimicrobial-resistance pat-terns of gastrointestinal pathogens, which are
seldom known. Moreover, these agents can elicit adverse reactions and can
promote the emergence of resistant organisms. However, for HIV-infected
travelers, antimicrobial prophylaxis may be considered, de-pending on the
level of immunosuppression and the region and duration of travel.
The use of fluoroquinolones such as ciprofloxacin (500 mg/d) can be considered
when prophylaxis is deemed necessary. As an alternative (e.g., for
children, pregnant women, and persons already taking TMP-SMZ for PCP
prophylaxis), TMP-SMZ may offer some protection against traveler's diarrhea. The risk of toxicity should be considered before treatment with TMP-SMZ
is initiated solely because of travel.
Antimicrobial agents such as fluoroquinolones (e.g., 500 mg of ciprofloxacin twice a day for 37 days) should be given to patients before their departure, to be taken empirically should traveler's diarrhea develop. Alternative antibiotics for children and pregnant women should be discussed. Travelers should consult a physician if their diarrhea is severe and does not respond to empirical therapy, if their stools contain blood, if fever is accompanied by shaking chills, or if dehydration develops. Antiperistaltic agents (e.g., diphenoxylate and loperamide) can be used for the treatment of mild diarrhea. However, the use of these drugs should be discontinued if symptoms persist beyond 48 hours. Moreover, these agents should not be administered to patients who have a high fever or who have blood in the stool.
Some experts recommend that HIV-infected persons who have Salmonella gastroenteritis be administered antimicrobial therapy to prevent extraintestinal spread. However, no controlled study has demonstrated a beneficial effect of such treatment, and some studies of immunocompetent persons have suggested that antimicrobial therapy can lengthen the shedding period. The fluoroquinolones primarily ciprofloxacin (750 mg twice a day for 14 days)can be used when antimicrobial therapy is chosen.
Prevention of Recurrence
HIV-infected persons who have Salmonella septicemia require
long-term therapy for the prevention of recurrence. The fluoroquinolones,
primarily ciprofloxacin, are usually the drugs of choice for susceptible
organisms.
Household contacts of HIV-infected persons who have salmonellosis or shigellosis should be evaluated for asymptomatic carriage of Salmonella or Shigella so that strict hygienic measures and/or antimicrobial therapy can be instituted and recurrent transmission to the HIV-infected person can be prevented.
Notes:
Pediatric Notes
Like HIV-infected adults, HIV-infected children should wash their
hands after handling pets (especially before eating) and should avoid contact
with pets' feces. Hand washing should be supervised.
HIV-exposed infants aged <3 months and all HIV-infected children who have severe immunosuppression should be administered treatment for Salmonella gastroenteritis to prevent extraintestinal spread (CIII). Possible choices of antibiotics include TMP-SMZ, ampicillin, cefotaxime, ceftriaxone, or chloramphenicol; ciprofloxacin should be used with caution and only if no alternatives exist.
HIV-infected children who have Salmonella septicemia should be offered long-term therapy for the prevention of recurrence. TMP-SMZ is the drug of choice; ampicillin or chloramphenicol can be used if the organism is susceptible. Ciprofloxacin should be used with caution and only if no alternatives exist.
Antiperistaltic drugs are not recommended for children.
Because both pregnancy and HIV infection confer a risk for listeriosis, pregnant HIV-infected women should heed recommendations concerned with this disease (BII).
Fluoroquinolones should not be used during pregnancy. TMP-SMZ may offer some protection against traveler's diarrhea.
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