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Review of the Causes and Management of Chronic Gastrointestinal Symptoms in Returned Travellers Referred to an Australian Infectious Diseases Service

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Review of the Causes and Management of Chronic Gastrointestinal Symptoms in Returned Travellers Referred to an Australian Infectious Diseases Service RESEARCH Review of the causes and management of chronic gastrointestinal symptoms in returned travellers referred to an Australian infectious diseases service Noha Ferrah, Karin Leder, Katherine Gibney Background t is estimated that 30–70% of the 1.1 billion overseas travellers in 2014 experienced traveller’s diarrhoea (TD). This Thirty to seventy per cent of overseas travellers experience I condition is defined as the passage of loose stools three traveller’s diarrhoea (TD), a potential cause of serious or more times in less than 24 hours during or shortly after gastrointestinal (GI) sequelae. However, there is limited returning from overseas travel.1 Diarrhoea is classified as acute evidence on the optimal management of TD. (fewer than two weeks), persistent (two to four weeks) or Objectives chronic (four weeks or longer). Acute diarrhoea accounts for the majority of TD cases, whereas persistent and chronic diarrhoea The objectives of this article are to characterise the aetiologies are less common, with estimated prevalences of 3% and 1–2% and management of returned travellers with ongoing GI respectively.1–3 Most cases of TD are caused by bacteria or symptoms referred to a specialist infectious diseases service. viruses and resolve within days, but some individuals experience persistent gastrointestinal (GI) symptoms.2 Causes of ongoing Methods GI symptoms in returned travellers may be categorised as:3 • parasitic infections, mainly Giardia and Entamoeba histolytica We conducted a retrospective medical record review of patients • unmasked GI disease such as inflammatory bowel disease referred to the Victorian Infectious Disease Service (VIDS) in 2013–15 with a history of overseas travel and GI symptoms (IBD) or malignancy present for longer than two weeks. For each diagnostic group, we • post-infectious sequelae, including post-infectious irritable compared demographic and travel characteristics, illness course, bowel syndrome (PI-IBS). investigation results, and number of and response to treatments. TD is an increasingly recognised cause of serious short-term and long-term GI sequelae.4 Proposed mechanisms include Results dysregulation of local immune and neuroendocrine systems, and alterations in the gut microbiome. Changes in the gut The most common diagnosis was parasitic infection (31 out of 65 microbiome may be induced by the initial episode of acute patients). Referral was made for infection with a controversial or diarrhoea5 and/or treatment with antimicrobial therapy.6 uncommon organism; negative microbiological findings +/– failed Chronic GI symptoms represent a significant clinical and metronidazole treatment; or severe or prolonged infections. public health issue, and are a common presentation in the 7 Discussion primary care setting. Among returned travellers, this often follows an acute travel-related episode of diarrhoea, with Our results highlight the utility of ordering more than one faecal considerable associated costs related to disability, reduced specimen for oocytes, cysts and parasites (O/C/P) examination, quality of life, lost income and healthcare expenditures.8 potential benefits of tinidazole use, and role of specialist services However, the burden of chronic illnesses associated with TD is for uncertain diagnoses and complex and/or unusual organisms. often under-recognised. © The Royal Australian College of General Practitioners 2016 AFP VOL.45, NO.5, MAY 2016 333 RESEARCH CHRONIC GASTROINTESTINAL SYMPTOMS Despite reviews and expert opinions discharged by the end of the study period, (Figure 1). The duration of diarrhoea on the management of chronic diarrhoea their outcome was recorded as unknown. and abdominal pain was longest in the in returned travellers,3 there is a lack of Data were collected retrospectively parasitic infection and PI-IBS groups clear evidence on optimal management by a review of electronic and hard copy (maximum duration of longer than to support the guidelines. Most studies medical record files to extract information 2.5 years). Significant impact on daily have either focused on acute TD on patients’: activities was reported in 14 cases, rather than long-term symptoms,9 –11 or • demographics (age, sex, country of consisting of hospitalisations and time restricted their analysis to the incidence birth and current residence) off work. and aetiologies of ongoing GI symptoms • travel histories (reason for travel, Across all diagnostic groups, 62 (95%) rather than management.12,13 Therefore, destination and duration) patients had microscopy testing for faecal research is needed to generate evidence • reason for seeking medical care oocyte, cyst and parasite (O/C/P), of and inform management protocols for • clinical symptoms and examination which 37 (60%) were positive. In patients these patients. findings with parasitic infections, 24/30 (80%) The aim of this study was • results of investigations O/C/P tests were positive (Figure 2) and to characterise the aetiologies, • diagnoses, treatment and outcomes. the remaining 20% were diagnosed investigations and treatments of patients Descriptive analysis was performed and using polymerase chain reaction (PCR), with persistent GI symptoms following comparisons made between diagnostic antigen and/or serological tests. In one travel who were referred to a specialist groups (Excel, Microsoft Corporation, case of discordant results (O/C/P positive infectious diseases service. 2013). This study was conducted as for Entamoeba spp. and PCR negative), an internal quality assurance audit and treatment was administered and resulted Methods hence human research ethics committee in symptom resolution. We conducted a retrospective review approval was not required. Seventeen patients whose first faecal of the medical files of patients who sample was negative had a second attended the Victorian Infectious Disease Results sample taken. Of these patients, nine Service (VIDS), an Australian tertiary-level Data were recorded for 65 patients (52%) had a positive microbiological result infectious diseases clinic at the Royal (Table 1), accounting for 159 visits on repeat testing. This suggests there Melbourne Hospital, from January 2013 (1.5% of all VIDS travel clinic outpatient was an incremental benefit in ordering to March 2015. Patients were included in consultations during the study period). more than one one faecal test before the study if they had: Fifty (77%) patients were under 40 years commencing treatment. Faecal PCR • travelled overseas in the previous two of age. Most were tourists travelling testing was performed when species years for longer than 30 days to high-risk identification could not be confirmed on • ongoing GI symptoms lasting longer zones (Table 1) in the Asia-Pacific region microscopy alone, such as for Entamoeba than two weeks, and (34 patients) or Africa (13 patients). Of the histolytica (n = 6). Other investigations • acquired their illness outside Australia. 65 patients, 36 (55%) were diagnosed included coeliac disease serology, An initial episode of acute TD was defined with an infectious cause, mostly parasitic thyroid function tests, malabsorption as the onset of diarrhoea during or within (Table 1). Non-infectious diagnoses markers and human immunodeficiency 10 days of returning to Australia from included PI-IBS (12 cases, 18%), virus (HIV) testing (all negative). Imaging travelling, and lasting fewer than two rheumatological diseases (five cases), IBD studies and upper/lower GI endoscopy weeks.1 Travel zone risk level was based (two cases) and rectal adenocarcinoma were ordered if indicated, and yielded on TD prevalence according to travel (one case). Thirty (46%) patients without positive findings in 11/23 cases (48%). destination by the Centers for Disease parasitic infection reported an initial Referral to gastroenterology services Control and Prevention (CDC; Table 1). episode of acute TD, which mostly abated was more frequent among patients Patients were recorded as having (n = 21, 70%), yet lingering GI symptoms without infectious causes identified abnormal investigation findings if tests prompted referral. Overall, of 52 patients (n =16/25, 47%). performed prior to or after referral to VIDS with known time between return and Prior to VIDS referral, 34 of the 65 consultation were abnormal. Diagnoses presentation, 38 (73%) presented more patients (52%) received were assigned by VIDS physicians on the than four weeks following their return to antimicrobial treatment (most basis of microbiology, clinical features, Australia. commonly metronidazole 400 mg, investigation results or response to Diarrhoea and abdominal pain were azithromycin 500 mg or doxycycline 200 treatment. Outcomes were recorded as the most frequently reported symptoms. mg). Fifty-two patients (80%) received resolution of symptoms and clinical state Most patients with a fever were therapy at VIDS (Figure 2). All patients at discharge. If patients had not been diagnosed with an infectious aetiology with microbiological evidence of infection 334 AFP VOL.45, NO.5, MAY 2016 © The Royal Australian College of General Practitioners 2016 CHRONIC GASTROINTESTINAL SYMPTOMS RESEARCH received targeted treatment, except Dientamoeba fragilis infection and known (Figure 2). Of 13 patients who did not those with Blastocystis hominis, of response, and one of seven empirically receive antimicrobial therapy, nine were whom only nine out of 13 were treated. treated with known response (Table 2). discharged symptom-free following Of 26 patients with negative
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