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## Complete Summary

#### GUIDELINE TITLE

Diagnosis and management of foodborne illnesses: a primer for physicians
and other health care professionals.

#### BIBLIOGRAPHIC SOURCE(S)

American Medical Association, American Nurses Association, American
Nurses Foundation, Centers for Disease Control and Prevention, Center
for Food Safety and Applied Nutrition, U.S. Food and Drug
Administration, Food Safety and Inspection Service, U.S. Department of
Agriculture. Diagnosis and management of foodborne illnesses: a primer
for physicians and other health care professionals. MMWR Recomm Rep 2004
Apr 16;53(RR-4):1-33.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15123984)

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Diagnosis and management of
foodborne illnesses: a primer for physicians. MMWR Recomm Rep 2001 Jan
26;50 (RR-2):1-69.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse (NGC)**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [July 08, 2008, Fluoroquinolones (ciprofloxacin, norfloxacin,
    ofloxacin, levofloxacin, moxifloxacin,
    gemifloxacin)](http://www.fda.gov/medwatch/safety/2008/safety08.htm#Fluoroquinolone):
    A BOXED WARNING and Medication Guide are to be added to the
    prescribing information to strengthen existing warnings about the
    increased risk of developing tendinitis and tendon rupture in
    patients taking fluoroquinolones for systemic use.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Foodborne illnesses (\"foodborne illnesses\" include any illness that is
related to food ingestion; gastrointestinal tract symptoms are the most
common clinical manifestations of foodborne illnesses).

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Emergency Medicine\
Family Practice\
Infectious Diseases\
Internal Medicine\
Pediatrics\
Preventive Medicine

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To help physicians and other health professionals in the prevention and
control of food-related disease outbreaks by providing practical and
concise information on the diagnosis, treatment, and reporting of
foodborne illnesses

#### TARGET POPULATION

Infants, children, adolescents and adults

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis**

1.  Differential diagnosis:

    -   Evaluation for signs and symptoms

    -   Differentiation between foodborn illness and viral syndromes

    -   Duration

    -   Associated foods

    -   Evaluation for underlying medical conditions (e.g., irritable
        bowel syndrome, inflammatory bowel disease, Crohn\'s disease)

2.  Microbiology testing:

    -   Stool cultures

    -   Blood cultures

    -   Direct antigen detection tests and molecular biology techniques

**Treatment**

1.  Supportive care

2.  Oral and/or intravenous hydration, with fluid +/- electrolyte
    replacement

3.  Gastric lavage

4.  Pharmacotherapy (penicillin, ciprofloxacin, erythromycin,
    trimethoprim-sulfamethoxazole, ampicillin, gentamicin, rifampin,
    doxycycline, ceftazidime, tetracycline, quinolones, bismuth sulfate,
    metronidazole, iodoquinol, paromomycin, spiramycin, pyrimethamine,
    nitazoxanide, mebendazole, albendazole, sulfadiazine, methylene
    blue, atropine, pralidoxime, antihistamines, corticosteroids,
    nalidixic acid, intravenous mannitol)

5.  Botulinum antitoxin and botulism immune globulin

**Surveillance and Reporting**

1.  Report potential foodborne illness

2.  Contact local or state health department with specific notifiable
    disease

3.  Report increases in unusual illnesses, symptom complexes, or disease
    complexes to public health authorities

4.  Follow the most current information on food safety

#### MAJOR OUTCOMES CONSIDERED

Disease outbreaks

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**[Diagnosing Foodborne Illnesses]{.underline}**

**Differential Diagnosis**

The presentation of a patient with a foodborne illness is often only
slightly different from that of a patient who presents with a viral
syndrome. In addition, viral syndromes are so common that it is
reasonable to assume that a percentage of those diagnosed with a viral
syndrome have actually contracted a foodborne illness. Therefore, the
viral syndrome must be excluded in order to suspect the foodborne
illness and take appropriate public health action. Fever, diarrhea, and
abdominal cramps can be present or absent in both cases so they are not
very helpful. The absence of myalgias or arthralgias would make a viral
syndrome less likely and a foodborne illness (that does not target the
neurologic system) more likely. Foodborne illnesses that do target the
neurologic system tend to cause paraesthesias, weakness and paralysis
that are distinguishable from myalgias or arthralgias (see below). The
presence of dysentery (bloody diarrhea) is also more indicative of a
foodborne illness, particularly if it is early in the course.

If any of the following signs and symptoms occur, alone or in
combination, laboratory testing may provide important diagnostic clues
(particular attention should be given to very young and elderly patients
and to immunocompromised patients, all of whom are more vulnerable):

-   Bloody diarrhea;

-   Weight loss;

-   Diarrhea leading to dehydration;

-   Fever;

-   Prolonged diarrhea (3 or more unformed stools per day, persisting
    several days);

-   Neurologic involvement such as paresthesias, motor weakness, cranial
    nerve palsies;

-   Sudden onset of nausea, vomiting, diarrhea;

-   Severe abdominal pain.

In addition to foodborne causes, a differential diagnosis of
gastrointestinal tract disease should include underlying medical
conditions such as irritable bowel syndrome; inflammatory bowel diseases
such as Crohn\'s disease or ulcerative colitis; malignancy; medication
use (including antibiotic-related *Clostridium difficile* toxin
colitis); gastrointestinal tract surgery or radiation; malabsorption
syndromes; immune deficiencies; and numerous other structural,
functional, and metabolic etiologies. Consideration also should be given
to exogenous factors such as the association of the illness with travel,
occupation, emotional stress, sexual practices, exposure to other ill
persons, recent hospitalization, child care center attendance, and
nursing home residence.

The table below presents a list of etiologic agents to consider for
various manifestations of foodborne illnesses.

+------------------------+---------------------------------------------+
| **Clinical             | **Potential Food-Related Agents to          |
| Presentation**         | Consider**                                  |
+========================+=============================================+
| Gastroenteritis        | Viral gastroenteritis, most commonly        |
| (vomiting as primary   | rotavirus in an infant or norovirus and     |
| symptom; fever and/or  | other caliciviruses in an older child or    |
| diarrhea also may be   | adult; or food poisoning due to preformed   |
| present)               | toxins (e.g., vomitoxin, *Staphylococcus    |
|                        | aureus* toxin, *Bacillus cereus* toxin) and |
|                        | heavy metals.                               |
+------------------------+---------------------------------------------+
| Noninflammatory        | Can be caused by virtually all enteric      |
| diarrhea (acute watery | pathogens (bacterial, viral, parasitic) but |
| diarrhea without       | is a classic symptom of:                    |
| fever/dysentery; some  |                                             |
| cases may present with | -   Enterotoxigenic *Escherichia coli*      |
| fever)\*               |                                             |
|                        | -   *Giardia*                               |
|                        |                                             |
|                        | -   *Vibrio cholerae*                       |
|                        |                                             |
|                        | -   Enteric viruses (astroviruses,          |
|                        |     noroviruses and other caliciviruses,    |
|                        |     enteric adenovirus, rotavirus)          |
|                        |                                             |
|                        | -   *Cryptosporidium*                       |
|                        |                                             |
|                        | -   *Cyclospora cayetanensis*               |
+------------------------+---------------------------------------------+
| Inflammatory diarrhea  | -   *Shigella* species                      |
| (invasive              |                                             |
| gastroenteritis;       | -   *Campylobacter* species                 |
| grossly bloody stool   |                                             |
| and fever may be       | -   *Salmonella* species                    |
| present)\*\*           |                                             |
|                        | -   Enteroinvasive *Escherichia coli*       |
|                        |                                             |
|                        | -   Enterohemorrhagic *Escherichia coli*    |
|                        |                                             |
|                        | -   *Escherichia coli* O157:H7              |
|                        |                                             |
|                        | -   *Vibrio parahaemolyticus*               |
|                        |                                             |
|                        | -   *Yersinia enterocolitica*               |
|                        |                                             |
|                        | -   *Entamoeba histolytica*                 |
+------------------------+---------------------------------------------+
| Persistent diarrhea    | Prolonged illness should prompt examination |
| (lasting               | for parasites, particularly in travelers to |
| [\>]{.underline}14     | mountainous or other areas where untreated  |
| days)                  | water is consumed. Consider *Cyclospora     |
|                        | cayetanensis*, *Cryptosporidium*,           |
|                        | *Entamoeba histolytica*, and *Giardia       |
|                        | lamblia*.                                   |
+------------------------+---------------------------------------------+
| Neurologic             | -   Botulism (*Clostridium botulinum*       |
| manifestations (e.g.,  |     toxin)                                  |
| paresthesias,          |                                             |
| respiratory            | -   Organophosphate pesticides              |
| depression,            |                                             |
| bronchospasm, cranial  | -   Thallium poisoning                      |
| nerve palsies)         |                                             |
|                        | -   Scombroid fish poisoning (histamine,    |
|                        |     saurine)                                |
|                        |                                             |
|                        | -   Ciguatera fish poisoning (ciguatoxin)   |
|                        |                                             |
|                        | -   Tetrodon fish poisoning (tetrodotoxin)  |
|                        |                                             |
|                        | -   Neurotoxic shellfish poisoning          |
|                        |     (brevitoxin)                            |
|                        |                                             |
|                        | -   Paralytic shellfish poisoning           |
|                        |     (saxitoxin)                             |
|                        |                                             |
|                        | -   Amnesic shellfish poisoning (domoic     |
|                        |     acid)                                   |
|                        |                                             |
|                        | -   Mushroom poisoning                      |
|                        |                                             |
|                        | -   Guillain-Barré Syndrome (associated     |
|                        |     with infectious diarrhea due to         |
|                        |     *Campylobacter jejuni*)                 |
+------------------------+---------------------------------------------+
| Systemic illness       | -   *Listeria monocytogenes*                |
| (e.g., fever,          |                                             |
| weakness, arthritis,   | -   *Brucella* species                      |
| jaundice)              |                                             |
|                        | -   *Trichinella spiralis*                  |
|                        |                                             |
|                        | -   *Toxoplasma gondii*                     |
|                        |                                             |
|                        | -   *Vibrio vulnificus*                     |
|                        |                                             |
|                        | -   Hepatitis A and E viruses               |
|                        |                                             |
|                        | -   *Salmonella* Typhi and *Salmonella*     |
|                        |     Paratyphi                               |
|                        |                                             |
|                        | -   Amebic liver abscess                    |
+------------------------+---------------------------------------------+

\* Noninflammatory diarrhea is characterized by mucosal hypersecretion
or decreased absorption without mucosal destruction and generally
involves the small intestine. Some affected patients may be dehydrated
because of severe watery diarrhea and may appear seriously ill. This is
more common in the young and the elderly. Most patients experience
minimal dehydration and appear mildly ill with scant physical findings.
Illness typically occurs with abrupt onset and brief duration. Fever and
systemic symptoms usually are absent (except for symptoms related
directly to intestinal fluid loss).

\*\* Inflammatory diarrhea is characterized by mucosal invasion with
resulting inflammation and is caused by invasive or cytotoxigenic
microbial pathogens. The diarrheal illness usually involves the large
intestine and may be associated with fever, abdominal pain and
tenderness, headache, nausea, vomiting, malaise, and myalgia. Stools may
be bloody and may contain many fecal leukocytes.

**Clinical Microbiology Testing**

Stool cultures are indicated if the patient is immunocompromised,
febrile, has bloody diarrhea, has severe abdominal pain, or if the
illness is clinically severe or persistent. Stool cultures are also
recommended if many fecal leukocytes are present. This indicates diffuse
colonic inflammation and is suggestive of invasive bacterial pathogens
such as *Shigella*, *Salmonella*, and *Campylobacter* species, and
invasive *Escherichia coli*. In most laboratories, routine stool
cultures are limited to screening for *Salmonella* and *Shigella*
species, and *Campylobacter jejuni/coli*. Cultures for *Vibrio* and
*Yersinia* species, *Escherichia coli* O157:H7, and *Campylobacter*
species other than *jejuni/coli* require additional media or incubation
conditions and therefore require advance notification or communication
with laboratory and infectious disease personnel.

Stool examination for parasites generally is indicated for patients with
suggestive travel histories, who are immunocompromised, who suffer
chronic or persistent diarrhea, or when the diarrheal illness is
unresponsive to appropriate antimicrobial therapy. Stool examination for
parasites is also indicated for gastrointestinal tract illnesses that
appear to have a long incubation period. Requests for ova and parasite
examination of a stool specimen will often enable identification of
*Giardia lamblia* and *Entamoeba histolytica*, but a special request may
be needed for detection of *Cryptosporidium* and *Cyclospora
cayetanensis*. Each laboratory may vary in its routine procedures for
detecting parasites so it is important to contact your laboratory.

Blood cultures should be obtained when bacteremia or systemic infection
are suspected.

Direct antigen detection tests and molecular biology techniques are
available for rapid identification of certain bacterial, viral, and
parasitic agents in clinical specimens. In some circumstances,
microbiologic and chemical laboratory testing of vomitus or implicated
food items also is warranted. For more information on laboratory
procedures for the detection of foodborne pathogens, consult an
appropriate medical specialist, clinical microbiologist, or state public
health laboratory.

**[Treating Foodborne Illnesses]{.underline}**

Selection of appropriate treatment depends on identification of the
responsible pathogen (if possible) and determining if specific therapy
is available. Many episodes of acute gastroenteritis are self-limiting
and require fluid replacement and supportive care. Oral rehydration is
indicated for patients who are mildly to moderately dehydrated;
intravenous therapy may be required for more severe dehydration. Routine
use of antidiarrheal agents is not recommended because many of these
agents have potentially serious adverse effects in infants and young
children. Choice of antimicrobial therapy should be based on:

-   Clinical signs and symptoms;

-   Organism detected in clinical specimens;

-   Antimicrobial susceptibility tests; and

-   Appropriateness of treating with an antibiotic (some enteric
    bacterial infections are best not treated).

Knowledge of the infectious agent and its antimicrobial susceptibility
pattern allows the physician to initiate, change, or discontinue
antimicrobial therapy. Such information also can support public health
surveillance of infectious disease and antimicrobial resistance trends
in the community. Antimicrobial resistance has increased for some
enteric pathogens, which requires judicious use of this therapy.

Suspected cases of botulism are treated with botulinum antitoxin. Equine
botulinum antitoxin for types A, B, and E can prevent the progression of
neurologic dysfunction if administered early in the course of illness.
Physicians and other health care professionals should notify their local
and state health departments regarding suspected cases of botulism. The
Centers for Disease Control and Prevention (CDC) maintains a 24-hour
consultation service to assist health care professionals with the
diagnosis and management of this rare disease.

The following tables summarize diagnostic features, laboratory testing
and treatment for bacterial, viral, parasitic, and noninfectious causes
of foodborne illness. (*Note: To print the following large tables, users
may have to change their printer settings to landscape, print on legal
size paper, and/or use a small font size.*)

**Foodborne Illnesses (Bacterial)**

  ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
  **Etiology**          **Incubation       **Signs and Symptoms** **Duration of      **Associated Foods** **Laboratory        **Treatment**
                        Period**                                  Illness**                               Testing**           
  --------------------- ------------------ ---------------------- ------------------ -------------------- ------------------- ------------------------------------------------------------
  *Bacillus anthracis*  2 days to weeks    Nausea, vomiting,      Weeks              Insufficiently       Blood.              Penicillin is first choice for naturally acquired
                                           malaise, bloody                           cooked contaminated                      gastrointestinal anthrax. Ciprofloxacin is second option.
                                           diarrhea, acute                           meat.                                    
                                           abdominal pain.                                                                    

  *Bacillus cereus*     1 to 6 hours       Sudden onset of severe 24 hours           Improperly           Normally a clinical Supportive care.
  (preformed                               nausea and vomiting.                      refrigerated cooked  diagnosis. Clinical 
  enterotoxin)                             Diarrhea may be                           and fried rice,      laboratories do not 
                                           present.                                  meats.               routinely identify  
                                                                                                          this organism. If   
                                                                                                          indicated, send     
                                                                                                          stool and food      
                                                                                                          specimens to        
                                                                                                          reference           
                                                                                                          laboratory for      
                                                                                                          culture and toxin   
                                                                                                          identification.     

  *Bacillus cereus*     10 to 16 hours     Abdominal cramps,      24 to 48 hours     Meats, stews,        Testing not         Supportive care
  (diarrheal toxin)                        watery diarrhea,                          gravies, vanilla     necessary,          
                                           nausea.                                   sauce.               self-limiting       
                                                                                                          (consider testing   
                                                                                                          food and stool for  
                                                                                                          toxin in            
                                                                                                          outbreaks).         

  *Brucella abortus*,   7 to 21 days       Fever, chills,         Weeks              Raw milk, goat       Blood culture and   [Acute]{.underline}: Rifampin and doxycycline daily for
  *Brucella                                sweating, weakness,                       cheese made from     positive serology.  [\>]{.underline}6 weeks. Infections with complications
  melitensis*, and                         headache, muscle and                      unpasteurized milk,                      require combination therapy with rifampin, tetracycline and
  *Brucella suis*                          joint pain, diarrhea,                     contaminated meats.                      an aminoglycoside.
                                           bloody stools during                                                               
                                           acute phase.                                                                       

  *Campylobacter        2 to 5 days        Diarrhea, cramps,      2 to 10 days       Raw and undercooked  Routine stool       Supportive care. For severe cases, antibiotics such as
  jejuni*                                  fever, and vomiting;                      poultry,             culture;            erythromycin and quinolones may be indicated early in the
                                           diarrhea may be                           unpasteurized milk,  *Campylobacter*     diarrheal disease. Guillain-Barré syndrome can be a
                                           bloody.                                   contaminated water.  requires special    sequelae.
                                                                                                          media and           
                                                                                                          incubation at 42    
                                                                                                          degrees C to grow.  

  *Clostridium          12 to 72 hours     Vomiting, diarrhea,    Variable (from     Home-canned foods    Stool, serum, and   Supportive care. *Botulinum* antitoxin is helpful if given
  botulinum*-children                      blurred vision,        days to months).   with a low acid      food can be tested  early in the course of the illness.
  and adults (preformed                    diplopia, dysphagia,   Can be complicated content, improperly  for toxin. Stool    
  toxin)                                   and descending muscle  by respiratory     canned commercial    and food can also   
                                           weakness.              failure and death. foods, home-canned   be cultured for the 
                                                                                     or fermented fish,   organism. These     
                                                                                     herb-infused oils,   tests can be        
                                                                                     baked potatoes in    performed at some   
                                                                                     aluminum foil,       state health        
                                                                                     cheese sauce,        department          
                                                                                     bottled garlic,      laboratories and    
                                                                                     foods held warm for  the Centers for     
                                                                                     extended periods of  Disease Control and 
                                                                                     time (e.g. in a warm Prevention (CDC).   
                                                                                     oven).                                   

  *Clostridium          3 to 30 days       In infants \<12        Variable           Honey, home-canned   Stool, serum, and   Supportive care. Botulism immune globulin can be obtained
  botulinum*-infants                       months, lethargy,                         vegetables and       food can be tested  from the [Infant Botulism Prevention
                                           weakness, poor                            fruits, corn syrup.  for toxin. Stool    Program](http://www.dhs.ca.gov/ps/dcdc/html/ibtindex.htm),
                                           feeding, constipation,                                         and food can also   Health and Human Services, California. Botulinum antitoxin
                                           hypotonia, poor head                                           be cultured for the is generally not recommended for infants.
                                           control, poor gag and                                          organism. These     
                                           sucking reflex.                                                tests can be        
                                                                                                          performed at some   
                                                                                                          state health        
                                                                                                          department          
                                                                                                          laboratories and    
                                                                                                          the CDC.            

  *Clostridium          8 to 16 hours      Watery diarrhea,       24 to 48 hours     Meats, poultry,      Stools can be       Supportive care. Antibiotics not indicated.
  perfringens* toxin                       nausea, abdominal                         gravy, dried or      tested for          
                                           cramps; fever is rare.                    precooked foods,     enterotoxin and     
                                                                                     time- and/or         cultured for        
                                                                                     temperature-abused   organism. Because   
                                                                                     food.                *Clostridium        
                                                                                                          perfringens* can    
                                                                                                          normally be found   
                                                                                                          in stool,           
                                                                                                          quantitative        
                                                                                                          cultures must be    
                                                                                                          done.               

  Enterohemorrhagic     1 to 8 days        Severe diarrhea that   5 to 10 days       Undercooked beef     Stool culture;      Supportive care, monitor renal function, hemoglobin, and
  *Escherichia coli*                       is often bloody,                          especially           *Escherichia coli*  platelets closely. Studies indicate that antibiotics may be
  (EHEC) including                         abdominal pain and                        hamburger,           0157:H7 requires    harmful. *Escherichia coli* 0157:H7 infection is also
  *Escherichia coli*                       vomiting. Usually                         unpasteurized milk   special media to    associated with hemolytic uremic syndrome (HUS), which can
  0157:H7 and other                        little or no fever is                     and juice, raw       grow. If            cause lifelong complications. Studies indicate that
  Shiga toxin-producing                    present. More common                      fruits and           *Escherichia coli*  antibiotics may promote the development of HUS.
  *Escherichia coli*                       in children \<4 years.                    vegetables (e.g.     0157:H7 is          
  (STEC)                                                                             sprouts), salami     suspected, specific 
                                                                                     (rarely), and        testing must be     
                                                                                     contaminated water.  requested. Shiga    
                                                                                                          toxin testing may   
                                                                                                          be done using       
                                                                                                          commercial kits;    
                                                                                                          positive isolates   
                                                                                                          should be forwarded 
                                                                                                          to public health    
                                                                                                          laboratories for    
                                                                                                          confirmation and    
                                                                                                          serotyping.         

  Enterotoxigenic       1 to 3 days        Watery diarrhea,       3 to \>7 days      Water or food        Stool culture. ETEC Supportive care. Antibiotics are not needed except in rare
  *Escherichia coli*                       abdominal cramps, some                    contaminated with    requires special    cases. Recommended antibiotics include TMP-SMX and
  (ETEC)                                   vomiting.                                 human feces.         laboratory          quinolones.
                                                                                                          techniques for      
                                                                                                          identification. If  
                                                                                                          suspected, must     
                                                                                                          request specific    
                                                                                                          testing.            

  *Listeria             9 to 48 hours for  Fever, muscle aches,   Variable           Fresh soft cheeses,  Blood or            Supportive care and antibiotics; Intravenous ampicillin,
  monocytogenes*        gastrointestinal   and nausea or                             unpasteurized milk,  cerebrospinal fluid penicillin, or TMP-SMX are recommended for invasive disease.
                        symptoms, 2 to 6   diarrhea. Pregnant                        inadequately         cultures.           
                        weeks for invasive women may have mild                       pasteurized milk,    Asymptomatic fecal  
                        disease.           flu-like illness, and                     ready-to-eat deli    carriage occurs;    
                                           infection can lead to                     meats, hot dogs.     therefore, stool    
                                           premature delivery or                                          culture usually not 
                                           stillbirth. Elderly or                                         helpful. Antibody   
                                           immunocompromised                                              to listeriolysin O  
                                           patients may have                                              may be helpful to   
                                           bacteremia or                                                  identify outbreak   
                                           meningitis.                                                    retrospectively.    

                        At birth and       Infants infected from                                                               
                        infancy            mother at risk for                                                                 
                                           sepsis or meningitis.                                                              

  *Salmonella* species  1 to 3 days        Diarrhea, fever,       4 to 7 days        Contaminated eggs,   Routine stool       Supportive care. Other than for *Salmonella typhi*,
                                           abdominal cramps,                         poultry,             cultures.           antibiotics are not indicated unless there is
                                           vomiting. *Salmonella                     unpasteurized milk                       extra-intestinal spread, or the risk of extra-intestinal
                                           typhi* and *Salmonella                    or juice, cheese,                        spread, of the infection. Consider ampicillin, gentamicin,
                                           paratyphi* produce                        contaminated raw                         TMP-SMX, or quinolones if indicated. A vaccine exists for
                                           typhoid with insidious                    fruits and                               *Salmonella typhi*.
                                           onset characterized by                    vegetables (alfalfa                      
                                           fever, headache,                          sprouts, melons).                        
                                           constipation, malaise,                    *Salmonella typhi*                       
                                           chills, and myalgia;                      epidemics are often                      
                                           diarrhea is uncommon,                     related to fecal                         
                                           and vomiting is                           contamination of                         
                                           usually not severe.                       water supplies or                        
                                                                                     street-vended foods.                     

  *Shigella* species    24 to 48 hours     Abdominal cramps,      4 to 7 days        Food or water        Routine stool       Supportive care. TMP-SMX recommended in the United States if
                                           fever, and diarrhea.                      contaminated with    cultures.           organism is susceptible; nalidixic acid or other quinolones
                                           Stools may contain                        fecal material.                          may be indicated if organism is resistant, especially in
                                           blood and mucus.                          Usually                                  developing countries.
                                                                                     person-to-person                         
                                                                                     spread, fecal-oral                       
                                                                                     transmission.                            
                                                                                     Ready-to-eat foods                       
                                                                                     touched by infected                      
                                                                                     food workers(e.g.,                       
                                                                                     raw vegetables,                          
                                                                                     salads, sandwiches).                     

  *Staphylococcus       1 to 6 hours       Sudden onset of severe 24 to 48 hours     Unrefrigerated or    Normally a clinical Supportive care.
  aureus* (preformed                       nausea and vomiting.                      improperly           diagnosis. Stool,   
  enterotoxin)                             Abdominal cramps.                         refrigerated meats,  vomitus, and food   
                                           Diarrhea and fever may                    potato and egg       can be tested for   
                                           be present.                               salads, cream        toxin and cultured  
                                                                                     pastries.            if indicated.       

  *Vibrio cholerae*     24 to 72 hours     Profuse watery         3 to 7 days.       Contaminated water,  Stool culture;      Support care with aggressive oral and intravenous
  (toxin)                                  diarrhea and vomiting, Causes             fish, shellfish,     *Vibrio cholerae*   rehydration. In cases of confirmed cholera, tetracycline or
                                           which can lead to      life-threatening   street-vended food   requires special    doxycycline is recommended for adults and TMP-SMX for
                                           severe dehydration and dehydration.       typically from Latin media to grow. If   children (\<8 years).
                                           death within hours.                       America or Asia.     *Vibrio cholerae*   
                                                                                                          is suspected, must  
                                                                                                          request specific    
                                                                                                          testing.            

  *Vibrio               2 to 48 hours      Watery diarrhea,       2 to 5 days        Undercooked or raw   Stool cultures.     Supportive care. Antibiotics are recommended in severe
  parahaemolyticus*                        abdominal cramps,                         seafood, such as     *Vibrio             cases: tetracycline, doxycycline, gentamicin, and
                                           nausea, vomiting.                         fish, shellfish.     parahaemolyticus*   cefotaxime.
                                                                                                          requires special    
                                                                                                          media to grow. If   
                                                                                                          *Vibrio             
                                                                                                          parahaemolyticus*   
                                                                                                          is suspected, must  
                                                                                                          request specific    
                                                                                                          testing.            

  *Vibrio vulnificus*   1 to 7 days        Vomiting, diarrhea,    2 to 8 days        Undercooked or raw   Stool, wound, or    Supportive care and antibiotics; tetracycline, doxycycline,
                                           abdominal pain,                           shellfish,           blood cultures.     and ceftazidime are recommended.
                                           bacteremia, and wound                     especially oysters;  *Vibrio vulnificus* 
                                           infections. More                          other contaminated   requires special    
                                           common in the                             seafood, and open    media to grow. If   
                                           immunocompromised, or                     wounds exposed to    *Vibrio vulnificus* 
                                           in patients with                          seawater.            is suspected, must  
                                           chronic liver disease                                          request specific    
                                           (presenting with                                               testing.            
                                           bullous skin lesions).                                                             
                                           Can be fatal in                                                                    
                                           patients with liver                                                                
                                           disease and the                                                                    
                                           immunocompromised.                                                                 

  *Yersinia             24 to 48 hours     Appendicitis-like      1 to 3 weeks,      Undercooked pork,    Stool, vomitus or   Supportive care, usually self-limiting. If septicemia or
  enterocolitica* and                      symptoms (diarrhea and usually            unpasteurized milk,  blood culture.      other invasive disease occurs, antibiotic therapy with
  *Yersinia                                vomiting, fever, and   self-limiting      tofu, contaminated   *Yersinia* requires gentamicin or cefotaxime (doxycycline and ciprofloxacin also
  pseudotuberculosis*                      abdominal pain) occur                     water. Infection has special media to    effective).
                                           primarily in older                        occurred in infants  grow. If suspected, 
                                           children and young                        whose caregivers     must request        
                                           adults. May have a                        handled              specific testing.   
                                           scarlatiniform rash                       chitterlings.        Serology is         
                                           with *Yersinia                                                 available in        
                                           pseudotuberculosis*.                                           research and        
                                                                                                          reference           
                                                                                                          laboratories.       
  ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

**Foodborne Illnesses (Viral)**

  ------------------------------------------------------------------------------------------------------------------------
  **Etiology**     **Incubation   **Signs and         **Duration   **Associated   **Laboratory Testing**  **Treatment**
                   Period**       Symptoms**          of Illness** Foods**                                
  ---------------- -------------- ------------------- ------------ -------------- ----------------------- ----------------
  Hepatitis A      28 days        Diarrhea; dark      Variable, 2  Shellfish      Increase in alanine     Supportive care.
                   average (15 to urine; jaundice;    weeks to 3   harvested from transferase (ALT),      Prevention with
                   50 days)       and flu-like        months       contaminated   bilirubin. Positive IgM immunization.
                                  symptoms (i.e.,                  waters, raw    and anti-hepatitis A    
                                  fever, headache,                 produce,       antibodies.             
                                  nausea, and                      contaminated                           
                                  abdominal pain).                 drinking                               
                                                                   water,                                 
                                                                   uncooked foods                         
                                                                   and cooked                             
                                                                   foods that are                         
                                                                   not reheated                           
                                                                   after contact                          
                                                                   with infected                          
                                                                   food handler.                          

  Noroviruses (and 12 to 48 hours Nausea, vomiting,   12 to 60     Shellfish,     Routine                 Supportive care
  other                           abdominal cramping, hours        fecally        reverse-transcriptase   such as
  caliciviruses)                  diarrhea fever,                  contaminated   polymerase chain        rehydration.
                                  myalgia, and some                foods,         reaction (RT-PCR) and   Good hygiene.
                                  headache. Diarrhea               ready-to-eat   electron microscopy     
                                  is more prevalent                foods touched  (EM) on fresh           
                                  in adults and                    by infected    unpreserved stool       
                                  vomiting is more                 food workers   samples. Clinical       
                                  prevalent in                     (salads,       diagnosis, negative     
                                  children.                        sandwiches,    bacterial cultures.     
                                                                   ice, cookies,  Stool is negative for   
                                                                   fruit).        white blood cells.      

  Rotavirus        1 to 3 days    Vomiting, watery    4 to 8 days  Fecally        Identification of virus Supportive care.
                                  diarrhea, low-grade              contaminated   in stool via            Severe diarrhea
                                  fever. Temporary                 foods.         immunoassay.            may require
                                  lactose intolerance              Ready-to-eat                           fluid and
                                  may occur. Infants               foods touched                          electrolyte
                                  and children,                    by infected                            replacement.
                                  elderly, and                     food workers                           
                                  immunocompromised                (salads,                               
                                  are especially                   fruits).                               
                                  vulnerable.                                                             

  Other viral      10 to 70 hours Nausea, vomiting,   2 to 9 days  Fecally        Identification of the   Supportive care,
  agents                          diarrhea, malaise,               contaminated   virus in early acute    usually mild,
  (astroviruses,                  abdominal pain,                  foods.         stool samples.          self-limiting.
  caliciviruses,                  headache, fever                  Ready-to-eat   Serology. Commercial    Good hygiene.
  adenoviruses,                                                    foods touched  enzyme-linked           
  parvoviruses)                                                    by infected    immunosorbent assay     
                                                                   food workers.  (ELISA) kits are now    
                                                                   Some           available to            
                                                                   shellfish.     adenoviruses and        
                                                                                  astroviruses.           
  ------------------------------------------------------------------------------------------------------------------------

**Foodborne Illnesses (Parasitic)**

  ------------------------------------------------------------------------------------------------------------------------------------------
  **Etiology**        **Incubation        **Signs and Symptoms**   **Duration   **Associated   **Laboratory Testing**    **Treatment**
                      Period**                                     of Illness** Foods**                                  
  ------------------- ------------------- ------------------------ ------------ -------------- ------------------------- -------------------
  *Angiostrongylus    1 week to           Severe headaches,        Several      Raw or         Examination of            Supportive care.
  cantonensis*        [\>]{.underline}1   nausea, vomiting, neck   weeks to     undercooked    cerebrospinal fluid (CSF) Repeat lumbar
                      month               stiffness, paresthesias, several      intermediate   for elevated pressure,    punctures and use
                                          hyperesthesias,          months       hosts (e.g.,   protein, leukocytes, and  of corticosteroid
                                          seizures, and other                   snails or      eosinophils; serologic    therapy may be used
                                          neurologic                            slugs),        testing using ELISA to    for more severely
                                          abnormalities.                        infected       detect antibodies to      ill patients.
                                                                                paratenic      *Angiostrongylus          
                                                                                (transport)    cantonensis*.             
                                                                                hosts (e.g.,                             
                                                                                crabs, fresh                             
                                                                                water shrimp),                           
                                                                                fresh produce                            
                                                                                contaminated                             
                                                                                with                                     
                                                                                intermediate                             
                                                                                or transport                             
                                                                                hosts.                                   

  *Cryptosporidium*   2 to 10 days        Diarrhea usually         May be       Any uncooked   Request specific          Supportive care,
                                          watery), stomach cramps, remitting    food or food   examination of the stool  self-limited. If
                                          upset stomach, slight    and          contaminated   for *Cryptosporidium*.    severe consider
                                          fever.                   relapsing    by an ill food May need to examine water paromomycin for 7
                                                                   over weeks   handler after  or food.                  days. For children
                                                                   to months    cooking,                                 aged 1-11 years,
                                                                                drinking                                 consider
                                                                                water.                                   nitazoxanide for 3
                                                                                                                         days.

  *Cyclospora         1 to 14 days,       Diarrhea (usually        May be       Various types  Request specific          TMP-SMX for 7 days.
  cayetanensis*       usually at least 1  watery), loss of         remitting    of fresh       examination of the stool  
                      week                appetite, substantial    and          produce        for *Cyclospora*. May     
                                          loss of weight, stomach  relapsing    (imported      need to examine water or  
                                          cramps, nausea,          over weeks   berries,       food.                     
                                          vomiting, fatigue.       to months    lettuce)                                 

  *Entamoeba          2 to 3 days to 1 to Diarrhea (often bloody), May be       Any uncooked   Examination of stool for  Metronidazole and a
  histolytica*        4 weeks             frequent bowel           protracted   food or food   cysts and parasites-at    luminal agent
                                          movements, lower         (several     contaminated   least 3 samples. Serology (iodoquinol or
                                          abdominal pain.          weeks to     by an ill food for long-term infections. paromomycin).
                                                                   several      handler after                            
                                                                   months)      cooking,                                 
                                                                                drinking                                 
                                                                                water.                                   

  *Giardia lamblia*   1 to 2 weeks        Diarrhea, stomach        Days to      Any uncooked   Examination of stool for  Metronidazole.
                                          cramps, gas.             weeks        food or food   ova and parasites- may    
                                                                                contaminated   need at least 3 samples.  
                                                                                by an ill food                           
                                                                                handler after                            
                                                                                cooking,                                 
                                                                                drinking                                 
                                                                                water.                                   

  *Toxoplasma gondii* 5 to 23 days        Generally asymptomatic,  Months       Accidental     Isolation of parasites    Asymptomatic
                                          20% may develop cervical              ingestion of   from blood or other body  healthy, but
                                          lymphadenopathy and/or a              contaminated   fluids; observation of    infected, persons
                                          flu-like illness.\                    substances     parasites in patient      do not require
                                          \                                     (e.g., soil    specimens via microscopy  treatment.
                                          [In immunocompromised                 contaminated   or histology. Detection   Spiramycin or
                                          patients]{.underline}:                with cat       of organisms is rare,     pyrimethamine plus
                                          central nervous system                feces, on      serology (reference       sulfadiazine may be
                                          (CNS) disease,                        fruits and     laboratory needed) can be used for
                                          myocarditis, or                       vegetables,    a useful adjunct in       immunocompromised
                                          pneumonitis is often                  raw or partly  diagnosing toxoplasmosis. persons, in
                                          seen.                                 cooked meat    However, lgM antibodies   specific cases.
                                                                                \[especially   may persist for 6 to 18   Pyrimethamine plus
                                                                                pork, lamb, or months and thus may not   sulfadiazine (with
                                                                                venison\]).    necessarily indicate      or without
                                                                                               recent infection. PCR of  steroids) may be
                                                                                               bodily fluids.\           given for ocular
                                                                                               \                         disease when
                                                                                               [For congenital           indicated. Folinic
                                                                                               infection]{.underline}:   acid is given with
                                                                                               isolation of *Toxoplasma  pyrimethamine plus
                                                                                               gondii* from placenta,    sulfadiazine to
                                                                                               umbilical cord, or infant counteract bone
                                                                                               blood. PCR of white blood marrow suppression.
                                                                                               cells, cerebrospinal      
                                                                                               fluid or amniotic fluid,  
                                                                                               or IgM and IgA serology,  
                                                                                               performed by a reference  
                                                                                               laboratory.               

  *Toxoplasma gondii* In infants at birth Treatment of the mother  Months       Passed from                               
  (congenital                             may reduce severity                   mother (who                              
  infection)                              and/or incidence of                   acquired acute                           
                                          congenital infection.                 infection                                
                                          Most infected infants                 during                                   
                                          have few symptoms at                  pregnancy) to                            
                                          birth. Later, they will               child.                                   
                                          generally develop signs                                                        
                                          of congenital                                                                  
                                          toxoplasmosis (mental                                                          
                                          retardation, severely                                                          
                                          impaired eyesight,                                                             
                                          cerebral palsy,                                                                
                                          seizures) unless the                                                           
                                          infection is treated.                                                          

  *Trichinella        1 to 2 days for     Acute: nausea, vomiting, Months       Raw or         Positive serology or      Supportive care
  spiralis*           initial symptoms;   diarrhea, fatigue,                    undercooked    demonstration of larvae   plus mebendazole or
                      others begin 2 to 8 fever, abdominal                      contaminated   via muscle biopsy.        albendazole.
                      weeks after         discomfort followed by                meat, usually  Increase in eosinophils.  
                      infection           muscle soreness,                      pork or wild                             
                                          weakness, and occasional              game meat                                
                                          cardiac and neurologic                (e.g., bear or                           
                                          complications.                        moose).                                  
  ------------------------------------------------------------------------------------------------------------------------------------------

**Foodborne Illnesses (Non-Infectious)**

  -----------------------------------------------------------------------------------------------------------------------------------------------
  **Etiology**        **Incubation   **Signs and Symptoms**            **Duration of  **Associated Foods**  **Laboratory      **Treatment**
                      Period**                                         Illness**                            Testing**         
  ------------------- -------------- --------------------------------- -------------- --------------------- ----------------- -------------------
  Antimony            5 minutes to 8 Vomiting, metallic taste.         Usually        Metallic container.   Identification of Supportive care.
                      hours; usually                                   self-limited                         metal in beverage 
                      \<1 hour                                                                              or food.          

  Arsenic             Few hours      Vomiting, colic, diarrhea.        Several days   Contaminated food.    Urine. May cause  Gastric lavage,
                                                                                                            eosinophilia.     bronchoalveolar
                                                                                                                              lavage (BAL),
                                                                                                                              (dimercaprol).

  Cadmium             5 minutes to 8 Nausea, vomiting, myalgia,        Usually        Seafood, oysters,     Identification of Supportive care.
                      hours; usually increase in salivation, stomach   self-limited   clams, lobster,       metal in food.    
                      \<1 hour       pain.                                            grains, peanuts.                        

  Ciguatera fish      2 to 6 hours   [Gastrointestinal]{.underline}:   Days to weeks  A variety of large    Radioassay for    Supportive care,
  poisoning                          abdominal pain, nausea, vomiting, to months      reef fish. Grouper,   toxin in fish or  intravenous
  (ciguatera toxin)                  diarrhea.                                        red snapper,          a consistent      mannitol. Children
                                                                                      amberjack, and        history.          more vulnerable.
                                                                                      barracuda (most                         
                                                                                      common).                                

                      3 hours        [Neurologic]{.underline}:                                                                 
                                     paresthesias, reversal of hot or                                                         
                                     cold, pain, weakness.                                                                    

                      2 to 5 days    [Cardiovascular]{.underline}:                                                             
                                     bradycardia, hypotension,                                                                
                                     increase in T wave abnormalities.                                                        

  Copper              5 minutes to 8 Nausea, vomiting, blue or green   Usually        Metallic container.   Identification of Supportive care.
                      hours; usually vomitus.                          self-limited                         metal in beverage 
                      \<1 hour                                                                              or food.          

  Mercury             1 week or      Numbness, weakness of legs,       May be         Fish exposed to       Analysis of       Supportive care.
                      longer         spastic paralysis, impaired       protracted     organic mercury,      blood, hair.      
                                     vision, blindness, coma. Pregnant                grains treated with                     
                                     women and the developing fetus                   mercury fungicides.                     
                                     are especially vulnerable.                                                               

  Mushroom toxins,    \<2 hours      Vomiting, diarrhea, confusion,    Self-limited   Wild mushrooms        Typical syndrome  Supportive care.
  short-acting                       visual disturbance, salivation,                  (cooking may not      and mushroom      
  (museinol,                         diaphoresis, hallucinations,                     destroy these         identified or     
  muscarine,                         disulfiram-like reaction,                        toxins).              demonstration of  
  psilocybin,                        confusion, visual disturbance.                                         the toxin.        
  coprinus                                                                                                                    
  artemetaris,                                                                                                                
  ibotenic acid)                                                                                                              

  Mushroom toxin,     4 to 8 hours   Diarrhea, abdominal cramps,       Often fatal    Mushrooms.            Typical syndrome  Supportive care;
  long-acting         diarrhea; 24   leading to hepatic and renal                                           and mushroom      life-threatening,
  (amanitin)          to 48 hours    failure.                                                               identified and/or may need life
                      liver failure                                                                         demonstration of  support.
                                                                                                            the toxin.        

  Nitrite poisoning   1 to 2 hours   Nausea, vomiting, cyanosis,       Usually        Cured meats, any      Analysis of the   Supportive care,
                                     headache, dizziness, weakness,    self-limited   contaminated foods,   food, blood.      methylene blue.
                                     loss of consciousness,                           spinach exposed to                      
                                     chocolate-brown colored blood.                   nitrification.                          

  Pesticides          Few minutes to Nausea, vomiting, abdominal       Usually        Any contaminated      Analysis of the   Atropine. 2-PAM
  (organophosphates   few hours      cramps, diarrhea, headache,       self-limited   food.                 food, blood.      (Pralidoxime) is
  or carbamates)                     nervousness, blurred vision,                                                             used when atropine
                                     twitching, convulsions,                                                                  is not able to
                                     salivation and meiosis.                                                                  control symptoms
                                                                                                                              and is rarely
                                                                                                                              necessary in
                                                                                                                              carbamate poisoning

  Puffer Fish         \<30 minutes   Paresthesias, vomiting, diarrhea, Death usually  Puffer fish.          Detection of      Life-threatening
  (tetrodotoxin)                     abdominal pain, ascending         in 4 to 6                            tetrodotoxin in   may need
                                     paralysis, respiratory failure.   hours                                fish.             respiratory
                                                                                                                              support.

  Scombroid           1 min to 3     Flushing, rash, burning sensation 3 to 6 hours   Fish: bluefin, tuna,  Demonstration of  Supportive care,
  (histamine)         hours          of skin, mouth and throat,                       skipjack, mackerel,   histamine in food antihistamines.
                                     dizziness, urticaria,                            marlin, escolar, and  or clinical       
                                     paresthesias.                                    mahi mahi.            diagnosis.        

  Shellfish toxins    Diarrheic      Nausea, vomiting, diarrhea, and   Hours to 2-3   A variety of          Detection of the  Supportive care,
  (diarrheic,         shellfish      abdominal pain accompanied by     days           shellfish, primarily  toxin in          generally
  neurotoxic,         poisoning      chills, headache, and fever.                     mussels, oysters,     shellfish; high   self-limiting.
  amnesic)            (DSP)-30 min                                                    scallops, and         pressure liquid   Elderly are
                      to 2 hours                                                      shellfish from the    chromatography.   especially
                                                                                      Florida coast and the                   sensitive to APS.
                                                                                      Gulf of Mexico.                         

                      Neurotoxic     Tingling and numbness of lips,                                                            
                      shellfish      tongue, and throat, muscular                                                             
                      poisoning      aches, dizziness, reversal of the                                                        
                      (NSP)-few      sensations of hot and cold,                                                              
                      minutes to     diarrhea, and vomiting.                                                                  
                      hours                                                                                                   

                      Amnesic        Vomiting, diarrhea, abdominal                                                             
                      shellfish      pain and neurological problems                                                           
                      poisoning      such as confusion, memory loss,                                                          
                      (ASP)-24 to 48 disorientation, seizure, coma.                                                           
                      hours                                                                                                   

  Shellfish toxins    30 min to 3    Diarrhea, nausea, vomiting        Days           Scallops, mussels,    Detection of      Life-threatening,
  (paralytic          hours          leading to paresthesias of mouth,                clams, cockles.       toxin in food or  may need
  shellfish                          lips, weakness, dysphasia,                                             water where fish  respiratory
  poisoning)                         dysphonia, respiratory paralysis.                                      are located; high support.
                                                                                                            pressure liquid   
                                                                                                            chromatography.   

  Sodium fluoride     Few min to 2   Salty or soapy taste, numbness of Usually        Dry foods (such as    Testing of        Supportive care.
                      hours          mouth, vomiting, diarrhea,        self-limited   dry milk, flour,      vomitus or        
                                     dilated pupils, spasms, pallor,                  baking powder, cake   gastric washings. 
                                     shock, collapse.                                 mixes) contaminated   Analysis of the   
                                                                                      with sodium           food.             
                                                                                      fluoride-containing                     
                                                                                      insecticides and                        
                                                                                      rodenticides.                           

  Thallium            Few hours      Nausea, vomiting, diarrhea,       Several days   Contaminated food.    Urine, hair.      Supportive care.
                                     painful paresthesias, motor                                                              
                                     polyneuropathy, hair loss.                                                               

  Tin                 5 min to 8     Nausea, vomiting, diarrhea.       Usually        Metallic container.   Analysis of the   Supportive care.
                      hours; usually                                   self-limited                         food.             
                      \<1 hour                                                                                                

  Vomitoxin           Few min to 3   Nausea, headache, abdominal pain, Usually        Grains, such as       Analysis of the   Supportive care.
                      hours          vomiting.                         self-limited   wheat, corn, barley.  food.             

  Zinc                Few hours      Stomach cramps, nausea, vomiting, Usually        Metallic container.   Analysis of the   Supportive care.
                                     diarrhea, myalgias.               self-limited                         food, blood and   
                                                                                                            feces, saliva or  
                                                                                                            urine.            
  -----------------------------------------------------------------------------------------------------------------------------------------------

**[Surveillance and Reporting of Foodborne Illnesses]{.underline}**

The following lists current reporting requirements for foodborne
diseases and conditions in the United States. National reporting
requirements are determined collaboratively by the Council of State and
Territorial Epidemiologists and the Centers for Disease Control and
Prevention (CDC).

**[Notifiable BACTERIAL Foodborne Diseases and Conditions]{.underline}**

-   Anthrax

-   Botulism

-   Brucellosis

-   Cholera

-   *Enterohemorrhagic Escherichia coli*

-   Hemolytic uremic syndrome, post-diarrheal

-   Listeriosis

-   Salmonellosis (other than *Salmonella Typhi*)

-   Shigellosis

-   Typhoid fever (*Salmonella Typhi* and *Salmonella Paratyphi*
    infections)

**[Notifiable VIRAL Foodborne Diseases and Conditions]{.underline}**

-   Hepatitis A

**[Notifiable PARASITIC Foodborne Diseases and Conditions]{.underline}**

-   Cryptosporidiosis

-   Cyclosporiasis

-   Giardiasis

-   Trichinellosis

In the United States, additional reporting requirements may be mandated
by state and territorial laws and regulations. Details on specific state
reporting requirements are available from the:

-   **Council of State and Territorial Epidemiologists**. Information is
    available electronically at
    <http://www.cste.org/nndss/reportingrequirements.htm>.

-   **Centers for Disease Control and Prevention**. Information is
    available electronically at
    [http://www.cdc.gov/epo/dphsi/phs/infdis2003.htm.](http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/mm4821a4.htm)

Typically, the appropriate procedure for physicians to follow in
reporting foodborne illnesses is to contact the local or state health
department whenever they identify a specific notifiable foodborne
disease. However, it is often unclear if a patient has a foodborne
illness prior to diagnostic tests, so health care professionals should
also report potential foodborne illnesses, such as when two or more
patients present with a similar illness that may have resulted from the
ingestion of a common food. Local health departments then report the
illnesses to the state health department and determine if further
investigation is warranted.

In addition to reporting cases of potential foodborne illnesses, it is
important for physicians to report noticeable increases in unusual
illnesses, symptom complexes, or disease patterns (even without
definitive diagnosis) to public health authorities. Prompt reporting of
unusual patterns of diarrheal/gastrointestinal tract illness, for
example, can allow public health officials to initiate an epidemiologic
investigation earlier than would be possible if the report awaited
definitive etiologic diagnosis.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

Not applicable

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

**General benefits include**:

Prevent and control food-related disease outbreaks.

**Specific benefits include**:

Foodborne disease reporting is not only important for disease prevention
and control, but more accurate assessments of the burden of foodborne
illness in the community occur when physicians report foodborne
illnesses to the local or state health department. In addition,
reporting of cases of foodborne illness by practicing physicians to the
local health department may help the health officer identify a foodborne
disease outbreak in the community. This may lead to early identification
and removal of contaminated products from the commercial market.
Occasionally, reporting may lead to the identification of a previously
unrecognized agent of foodborne illness. Reporting also may lead to
identification and appropriate management of human carriers of known
foodborne pathogens, especially those with high-risk occupations for
disease transmission such as food workers.

**Subgroups Most Likely to Benefit**:

Young, elderly, and immunocompromised patients

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This primer is not a clinical guideline or definitive resource for the
diagnosis and treatment of foodborne illness. Safe food handling
practices and technologies (e.g., irradiation, food processing and
storage) also are not addressed.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

American Medical Association, American Nurses Association, American
Nurses Foundation, Centers for Disease Control and Prevention, Center
for Food Safety and Applied Nutrition, U.S. Food and Drug
Administration, Food Safety and Inspection Service, U.S. Department of
Agriculture. Diagnosis and management of foodborne illnesses: a primer
for physicians and other health care professionals. MMWR Recomm Rep 2004
Apr 16;53(RR-4):1-33.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15123984)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2001 Jan (revised 2004 Apr 16)

#### GUIDELINE DEVELOPER(S)

American Medical Association - Medical Specialty Society\
Center for Food Safety and Applied Nutrition - Federal Government Agency
\[U.S.\]\
Centers for Disease Control and Prevention - Federal Government Agency
\[U.S.\]\
Food Safety and Inspection Service - Federal Government Agency \[U.S.\]

#### GUIDELINE DEVELOPER COMMENT

This primer was developed collaboratively by the American Medical
Association, the Centers for Disease Control and Prevention (CDC), the
Center for Food Safety and Nutrition, Food and Drug Administration
(U.S.), and the Food Safety and Inspection Service, Department of
Agriculture (U.S.) as part of the National Food Safety Initiative
implemented under former President William Jefferson Clinton.

#### SOURCE(S) OF FUNDING

United States Government

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Writing/Working Group Members*: American Medical Association: LJ Tan,
PhD (Working Group Chair); Jim Lyznicki, MS, MPH Centers for Disease
Control and Prevention: Penny M. Adcock, MD; Eileen Dunne, MD, MPH;
Julia Smith, MPH Center for Food Safety and Applied Nutrition, U.S. Food
and Drug Administration: Eileen Parish, MD; Arthur Miller, PhD, Howard
Seltzer Food Safety and Inspection Service, U.S. Department of
Agriculture: Ruth Etzel, MD, PhD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Elaine F. Brainerd, R.N., M.A., has indicated that she has a financial
relationship with Centers for Disease Control and Prevention (CDC)
because she is the Director of a Food Safe Schools project that is
funded under a cooperative agreement by CDC. The remaining preparers
have signed a conflict of interest disclosure form that verifies no
conflict of interest.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Diagnosis and management of
foodborne illnesses: a primer for physicians. MMWR Recomm Rep 2001 Jan
26;50 (RR-2):1-69.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Centers for Disease Control and
Prevention (CDC) Web site](http://www.cdc.gov/mmwr/PDF/rr/rr5304.pdf).

Print copies: Available from the Centers for Disease Control and
Prevention, MMWR, Atlanta, GA 30333. Additional copies can be purchased
from the Superintendent of Documents, U.S. Government Printing Office,
Washington, DC 20402-9325; (202) 783-3238. Copies are also available
from the American Medical Association, 515 North State Street, Chicago,
IL 60610; Web site: [www.ama-assn.org](http://www.ama-assn.org/).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on May 8, 2001. This summary was
updated on August 17, 2004. This summary was updated by ECRI Institute
on July 28, 2008 following the U.S. Food and Drug Administration
advisory on fluoroquinolone antimicrobial drugs.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which may be
subject to the guideline developer\'s copyright restrictions. (The
original full-text guideline was reprinted in the *MMWR*, the source
cited for this NGC Guideline Summary, with the permission of the
American Medical Association; the Center for Food Safety and Nutrition,
Food and Drug Administration; and the Food Safety and Inspection
Service, U.S. Department of Agriculture.)

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008