Bacterial Enteric Infections

Prevention of Exposure

Food
(1) Health-care providers should advise HIV-infected persons not to eat raw or undercooked eggs (including foods that may contain raw eggs [e.g., some preparations of hollandaise sauce, Caesar and other salad dressings, and mayonnaise]); raw or undercooked 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^o). Produce should be washed thoroughly before being eaten (BIII).

(2) 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).

(3) 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 (CIII).

Pets
(4) When obtaining a new pet, HIV-infected persons should avoid young animals (aged <6 months), especially those that have diarrhea (BIII).

(5) 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.

(6) HIV-infected persons should wash their hands after handling pets (especially before eating) and should avoid contact with pets' feces (BIII).

(7) HIV-infected persons should avoid contact with reptiles (e.g., snakes, lizards, iguanas, and turtles) because of the risk of salmonellosis (BIII).

Travel
(8) 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 (AII). Treatment of water with iodine or chlorine may not be as effective as boiling but can be used when boiling is not practical (BIII).

Prevention of Disease
(9) Prophylactic antimicrobial agents are not generally recommended for travelers (DIII). The effectiveness of these agents depends on local antimicrobial-resistance patterns 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, depending on the level of immunosuppression and the region and duration of travel (CIII). The use of fluoroquinolones such as ciprofloxacin (500 mg/d) can be considered when prophylaxis is deemed necessary (BIII). 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 (BIII). The risk of toxicity should be considered before treatment with TMP-SMZ is initiated solely because of travel.

(10) Antimicrobial agents such as fluoroquinolones should be given to patients before their departure, to be taken empirically (e.g., 500 mg of ciprofloxacin twice a day for 3-7 days) should traveler's diarrhea develop (BIII). Fluoroquinolones should be avoided in children < 18 years and pregnant women, and alternative antibiotics should be considered (BIII). 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 (AII).

(11) 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 (CIII).

Prevention of Recurrence
(12) HIV-infected persons who have Salmonella septicemia require long-term therapy (i.e., secondary prophylaxis, chronic maintenance therapy), for the prevention of recurrence. The fluoroquinolones, primarily ciprofloxacin, are usually the drugs of choice for susceptible organisms (BII).

(13) Household contacts of HIV-infected persons who have salmonellosis or shigellosis should be evaluated for persistent 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 (CIII).

Notes

Pediatric Notes
(14) 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 (BIII).

(15) 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; fluoroquinolones should be used with caution and only if no alternatives exist.

(16) HIV-infected children who have Salmonella septicemia should be offered long-term therapy for the prevention of recurrence (CIII). TMP-SMZ is the drug of choice; ampicillin or chloramphenicol can be used if the organism is susceptible. Fluoroquinolones should be used with caution and only if no alternative exists.

(17) Antiperistaltic drugs are not recommended for children (DIII).

Notes Regarding Pregnancy
(18) Because both pregnancy and HIV infection confer a risk for listeriosis, pregnant HIV-infected women should heed recommendations concerned with this disease (BII).

(19) Since extra-intestinal spread of Salmonella during pregnancy may lead to infection of the placenta and amniotic fluid with pregnancy loss similar to that seen with Listeria monocytogenes, pregnant women with Salmonella gastroenteritis should receive treatment (BIII). Possible choices for treatment include ampicillin, cefotaxime, ceftriaxone, or TMP-SMZ. Fluoroquinolones should be avoided.

(20) Fluoroquinolones should not be used during pregnancy. TMP-SMZ may offer some protection against traveler's diarrhea.

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