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CHAPTER 77: Management of the Critically Ill Traveler 711

workers and visitors should use gloves and gowns when entering the • Schmidt ML, Gilligan PH. Clostridium difficile testing algorithms:
room and having contact with a patient with suspected or proven CDI. what is practical and feasible? Anaerobe. 2009;15(6):270-273.
Hand hygiene is another important aspect in prevention. Because C dif-
ficile has a spore form, it is resistant to killing by alcohol, so soap and • Vaishnavi C. Established and potential risk factors for Clostridum
water should be used for hand disinfection. The mechanical action of difficile infection. Indian J Med Microbiol. 2009;27(4):289-300.
soap and water appears to be more effective in removing spores from • Zar FA, Bakkanagari SR, Moorthi KM, Davis MB. A com-
the contaminated hands of health care personnel. Patients with CDI parison of vancomycin and metronidazole for the treatment of
should have a private room or cohort patients when private rooms are Clostridium difficile-associated diarrhea, stratified by disease
not available and a dedicated commode should be used for each patient. severity. Clin Infect Dis. 2007;45(3):302-307.
Environmental cleaning and disinfection should be done with chlorine-
containing agents or other sporicidal agent. Replacement of electronic
rectal thermometers with single use rectal thermometers has also been
associated with a reduction in CDI incidence. 28 REFERENCES
Decreasing patient risk factors is another important area of prevention
and judicious use of antibiotics is one area of particular interest. Antibiotic Complete references available online at www.mhprofessional.com/hall
use is one of the most significant risk factors for CDI. In the critical care
setting limiting antibiotic use is difficult, especially in the setting of septic
shock. Antimicrobial stewardship programs have been implemented to CHAPTER Management of the
help minimize antibiotics use and duration. When available they should
antimicrobial use. The use of probiotics in critically ill has been another 77 Critically Ill Traveler
serve as a resource for physicians to help make prudent decisions on
28
area of interest. Studies have looked at their use in the treatment and Christian Sandrock
prevention of C difficile infection, acute pancreatitis and prevention of Hugh Black
aspiration pneumonia. However, systematic review of the literature has
not demonstrated clear evidence to support the routine use of probiotics
in the adult intensive care unit or in the prevention of CDI. This may be KEY POINTS
due to the lack of large randomized controlled trials. 48,49 • The critically ill traveler can provide a diagnostic dilemma for the
clinician given the wide array of causative agents.
• The patient’s travel history can lay a foundation for an epidemio-
KEY REFERENCES logical-based approach to therapy.
• Certain infectious agents that respond to antimicrobial therapy
• Baehr PH, McDonald GB. Esophageal infections: risk fac- must be considered early, with rapid administration of the appro-
tors, presentation, diagnosis, and treatment. Gastroenterology. priate treatment medications. These include malaria, rickettsial
1994;106(2):509-532. disease, meningococcus, plague, tularemia, and influenza.
• Bobo LD, Dubberke ER. Recognition and prevention of hospital- • Viral syndromes such as Middle East respiratory syndrome corona-
associated enteric infections in the intensive care unit. Crit Care virus (MERS-CoV), viral hemorrhagic fever (VHF), Ebola, and den-
Med. 2010;38(suppl 8):S324-S334. gue are managed with supportive care only, as there are no available
• Chapman MJ, Nguyen NQ, Fraser RJ. Gastrointestinal motil- treatment medications.
ity and prokinetics in the critically ill. Curr Opin Crit Care. • The management of the critically ill traveler includes early isola-
2007;13(2):187-194. tion and HCW protection should be initiated until a diagnosis can
• Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guide- be determined.
lines for Clostridium difficile infection in adults: 2010 update by
the society for healthcare epidemiology of America (SHEA) and
the infectious diseases society of America (IDSA). Infect Control
Hosp Epidemiol. 31(5):431-455. INTRODUCTION
• Johnson S, Louie TJ, Gerding DN, et al. Vancomycin, metronida- International travel is a fact of modern life. In 2000, nearly 700 million
1-3
zole, or tolevamer for Clostridium difficile infection: results from people worldwide visited a separate country from their residence. In
two multinational, randomized, controlled trials. Clin Infect Dis. 2006, roughly 30 million US citizens left the country and in 2007, 14% of
2014; Epub ahead PMID 24799326. the US population made a total of 64 million trips outside the borders
4-8
• Lee CH, Belanger JE, Kassam Z, et al. The outcome and long-term of the USA. First- and second-generation immigrants in the developed
follow-up of 94 patients with recurrent and refractory Clostridium world, who return to countries of origin while visiting friends and rela-
9
difficile infection using single to multiple fecal microbiota trans- tives, constitute up to 40% of all travelers from the United States.
plantation via retention enema. Eur J Clin Microbiol Infect Dis. Both returning travelers and local visitors can present with disease
2014; Epub ahead PMID 24627239. related to travel. Much of this disease will be present on arrival, or
develop shortly thereafter. Only a minority will occur while undergoing
• Pappas PG, Kauffman CA, Andes D, et al. Clinical practice travel, requiring a return to the home country, and of these returns, an
guidelines for the management of candidiasis: 2009 update even smaller minority will be critically ill. 4,6,7 Of 100,000 travelers to the
by the Infectious Diseases Society of America. Clin Infect Dis. developing world, roughly 300 will undergo hospitalization, 50 will be
2009;48(5):503-535. air evacuated, and 1 will die. The major causes of mortality and serious
2,3
• Robertson MS, Clancy RL, Cade JF. Helicobacter pylori in morbidity associated with travel are cardiovascular disease and trauma
intensive care: why we should be interested. Intensive Care Med. sustained from motor vehicle accidents. 2,3,5 Studies performed in the
2003;29(11):1881-1888. late 20th century suggest that infectious diseases account for less than
• Sack DA, Sack RB, Nair GB, Siddique AK. Cholera. Lancet. 5% of travel-associated mortality. 4,6,7 Trends in international migration
2004;363(9404):223-233. and travel, however, are likely to cause an increase in people returning
to the developing world with severe infections. Currently 50 million

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