Treatment of Foodborne Gastroenteritis

Key Points
General Considerations
Treatment With Antimicrobial Agents
—Campylobacter
—Cryptosporidium parvum
—Cyclospora cayetanensis
—Entamoeba histolytica
—E coli: STEC
—E coli: ETEC
—Giardia lamblia
—Isospora belli
—Plesiomonas shigelloides
—Salmonella (nontyphoidal)
—Shigella
—Vibrio cholerae
—Vibrio parahaemolyticus
Clinical Considerations
—Common Epidemiologic Associations for Foodborne Pathogens
References

Key Points

Foodborne disease is a heterogeneous group of illnesses caused by a variety of infectious (viruses, bacteria, and parasites) and noninfectious agents.
Most illnesses require only supportive care (eg, rehydration).
Antimicrobial therapy is appropriate for gastroenteritis caused by Cyclospora cayetanensis, Entamoeba histolytica, Giardia lamblia, Isospora belli, and Shigella.
Antimicrobial therapy also is appropriate for selected cases of traveler's diarrhea (eg, infection caused by enterotoxigenic Escherichia coli [ETEC]); for Salmonella infections in infants, older patients, and patients with underlying illnesses; and for severe infections caused by Campylobacter, Cryptosporidium parvum, Vibrio cholerae, and Yersinia enterocolitica.
Antimicrobial agents should not be used to treat gastrointestinal infections caused by E coli O157:H7.
Antimotility agents should not be administered to patients with bloody diarrhea or suspected infection with Shiga toxin–producing E coli (STEC), including E coli O157:H7.
Antibiotic resistance among various bacteria that cause foodborne disease is increasing; current resistance patterns should be taken into consideration when prescribing antibacterial agents to treat such infections.

General Considerations

Oral rehydration therapy is particularly important for management of diarrheal illness in young children and elderly adults. The American Academy of Pediatrics (AAP) published a practice guideline in 1996that provides parameters for assessing and treating dehydration in children (see References: AAP: The management of acute gastroenteritis in young children).
Antimotility agents should not be administered to patients with bloody diarrhea or suspected infection with Shiga toxin–producing Escherichia coli, including E coli O157:H7.
The AAP guideline does not recommend use of the following agents for treatment of acute diarrheal illness in pediatric patients:

Agents that alter intestinal motility (eg, loperamide, opiates)
Agents that alter secretion (eg, bismuth subsalicylate)
Adsorbents (eg, kaolin pectin)
Lactobacillus-containing compounds

Treatment With Antimicrobial Agents

Foodborne gastrointestinal illnesses that require treatment with antimicrobial agents are outlined in the table below. Treatment recommendations for systemic infections are not included.

Recommendations for Tr eatment of Foodborne Gastroenteritis by Etiology*†
Campylobacter species
Considerations	—Antimicrobial therapy should be reserved for use in severe cases only. —Resistance to fluoroquinolones is increasing, thereby limiting the effectiveness of these agents (see References: Allos 2001, Engberg 2001, Smith 1999).
Recommended therapy‡
Immunocompetent patients	Adult (for severe cases, choose one): —Erythromycin stearate, 500 mg PO twice daily for 5 days —Azithromycin, 500 mg PO daily for 3 days —Ciprofloxacin, 500 mg PO twice daily for 3 days§ (Warning: rate of resistance is increasing, as noted above) Pediatric (for severe cases, choose one): —Erythromycin, 30-50 mg/kg/day PO in 2-4 divided doses for 5-7 days —Azithromycin, 5-12 mg/kg PO once daily for 5 days —Tetracycline, 20-50 mg/kg/day (maximum 2 g/day) PO in 4 divided doses for 3 days (generally should not be given to patients <8 yr of age)
Immunocompromised patients	Same, but may require prolonged therapy
Cryptosporidium parvum
Considerations	—Treatment should be considered for severe cases (see References: Chen 2002). —It is unclear whether paromomycin offers benefit for HIV-infected patients (see References: Hewitt 2000). —Highly active antiretroviral therapy including a protease inhibitor is warranted for AIDS patients to improve immune function (see References: Carr 1998, Miller 1998).
Recommended therapy‡
Immunocompetent patients	Adult (for severe cases, choose one): —Paromomycin, 500 mg PO 3 times daily for 7 days —Nitazoxanide, 500 mg PO twice daily for 3 days (see References: Chen 2002, Rossignol 1998, Rossignol 2001). Pediatric (for severe cases, choose one): —Paromomycin, 25-35 mg/kg/day PO in 2-4 divided doses for 7 days (appropriate duration uncertain) —Nitazoxanide, 100 mg PO twice daily for 3 days
Immunocompromised patients	Adult (choose one): —Paromomycin, 500 mg PO 3 times daily for 14-28 days, then twice daily if needed —Nitazoxanide, 500 mg–1 gm PO twice daily for up to 14 days (see References: Chen 2002, Rossignol 1998)
Cyclospora cayetanensis
Considerations	—TMP/SMX is the treatment of choice. —Ciprofloxacin not as effective but may be an alternative, particularly for HIV-infected persons (see References: Verdier 2000).
Recommended therapy‡
Immunocompetent patients	Adult (choose one): —TMP/SMX, 1 DS tablet PO twice daily for 7 days —Ciprofloxacin, 500 mg PO twice daily for 7 days§ Pediatric: —TMP/SMX, 6-12 mg/kg/day TMP PO in 2 divided doses for 7 days
Immunocompromised patients	Adult (choose one): —TMP/SMX, 1 DS tablet PO 4 times daily for 10 days followed by 1 DS tablet PO 3 times/wk indefinitely as prophylaxis —Ciprofloxacin, 500 mg PO twice daily for 7 days§
Entamoeba histolytica
Considerations	—Invasive disease (ie, abscesses, colitis) should be treated with metronidazole and a luminal agent (iodoquinol, paromomycin, or diloxanide furoate [available only from CDC]). —Asymptomatic colonization should be treated with a luminal agent alone (see References: Petri 1999). —In cases of asymptomatic colonization where a luminal agent cannot be used, treatment with metronidazole and testing for cure with stool antigen detection test may be reasonable (see References: Petri 1999). —Entamoeba dispar does not require treatment.
Recommended therapy‡
Immunocompetent patients	Adult: Metronidazole, 750 mg PO 3 times daily for 5-10 days plus one of the following: —Iodoquinol, 650 mg PO 3 times daily for 20 days —Paromomycin, 500 mg PO 3 times daily for 7 days —Diloxanide furoate, 500 mg PO 3 times daily for 10 days (available only from CDC) Pediatric: Metronidazole, 35-50 mg/kg/day PO in 3 divided doses for 10 days plus —Iodoquinol, 30-40 mg/kg/day (maximum 2 g) PO in 3 divided doses for 20 days or —Paromomycin, 25-35 mg/kg/day PO in 3 divided doses for 7 days
Immunocompromised patients	Same
Escherichia coli: STEC (Shiga toxin–producing E coli, including serotype O157:H7)
Considerations	—Antibiotics may increase the risk of HUS; therefore, antibiotics should not be used to treat these infections (see References: Wong 2000). —Avoid antimotility drugs.
Escherichia coli: ETEC (enterotoxigenic E coli)
Considerations	—Most laboratories do not routinely identify these organisms; however, they are a common cause of traveler's diarrhea. —Illness is self-limited, but empirical therapy of traveler's diarrhea (ie, presumed ETEC infection) has been shown to shorten illness duration.
Recommended therapy‡
Immunocompetent patients	Adult (choose one): —TMP/SMX, 1 DS tablet PO twice daily for 3 days —Ciprofloxacin, 500 mg PO twice daily for 3 days§ —Ofloxacin, 300 mg PO twice daily for 3 days§ —Norfloxacin, 400 mg PO twice daily for 3 days§ Pediatric: TMP/SMX, 8-12 mg/kg/day TMP PO in 2 divided doses for 3 days
Immunocompromised patients	Same
Giardia lamblia
Considerations	—Some experts will consider empirical therapy for persons with diarrhea lasting longer than 10-14 days if other evaluations are negative, especially if history is suggestive of exposure. —If therapy fails, patient should be re-treated (ie, consider higher dose of metronidazole [750 mg] with or without quinacrine [100 mg PO TID for 14 days]) (see References: Nash 2001).
Recommended therapy‡
Immunocompetent patients	Adult (choose one): —Metronidazole, 250-750 mg PO 3 times daily for 7-10 days —Paromomycin (not absorbed; may be used to treat pregnant women), 500 mg PO 3 times daily for 7 days Pediatric: —Metronidazole, 15 mg/kg/day PO in 3 divided doses for 5-7 days —Paromomycin, 25-35 mg/kg/day PO in 3 divided doses for 7 days —Albendazole, 400 mp PO daily for 5 days (children ≥2 yr)
Immunocompromised patients	Same
Isospora belli
Considerations	—TMP/SMX is the treatment of choice. —Ciprofloxacin is not as effective but may be an alternative in HIV-infected persons (see References: Verdier 2000).
Recommended therapy‡
Immunocompetent patients	Adult (choose one): —TMP/SMX, 1 DS tablet PO twice daily for 7-10 days —Ciprofloxacin, 500 mg PO twice daily for 7 days§ Pediatric (choose one): —TMP/SMX, 8-12 mg/kg/day TMP PO in 2 divided doses for 7 days —Sulfadoxine/pyrimethamine, 1/4 tablet–3 tablets (dose depends on child's age) PO 1 or 2 times daily for 10 days (see References: AAP: Isosporiasis)
Immunocompromised patients	Adult: TMP/SMX, 1 DS tablet PO 4 times daily for 10 days, followed by —TMP/SMX, 3 times weekly or —Sulfadoxine/pyrimethamine, 1 tablet PO weekly indefinitely
Plesiomonas shigelloides
Considerations	Most infections are relatively mild and self-limited; however, anecdotal reports suggest that TMP/SMX or other agents may shorten duration of symptoms.
Recommended therapy‡
Immunocompetent patients	Adult (choose one): —TMP/SMX, 1 DS tablet PO twice daily for 3 days —Ciprofloxacin, 500 mg PO twice daily for 3 days§ —Ofloxacin, 300 mg PO twice daily for 3 days§ —Norfloxacin, 400 mg PO twice daily for 3 days§ Pediatric: TMP/SMX, 8-12 mg/kg/day TMP in 2 divided doses PO for 3 days
Immunocompromised patients	Same
Salmonella species (nontyphoidal)
Considerations	—Routine antimicrobial treatment of gastroenteritis is not recommended but should be considered for severe illness. —Patients <6 mo or >50 yr of age or with certain underlying conditions (eg, valvular heart disease, malignancy, immunosuppression, uremia) should be treated. —Use of antibiotics may prolong stool shedding of organisms. —Resistance to quinolones is increasing in the United States and elsewhere (see References: Chiu 2002, Herikstad 1997, Schwartz 2002, Threlfall 1999). —Multidrug-resistant Salmonella strains (notably, but not exclusively, DT104) and strains resistant to ceftriaxone have been increasingly recognized in the United States and elsewhere (see References: CDC 2002; Dunne 2000, Ribot 2002, White 2002). —According to AAP, duration of therapy for children depends on site of infection, host, and clinical response (see References: AAP: Salmonella infections).
Recommended therapy‡
Immunocompetent patients	Adult (for severe cases, choose one): —TMP/SMX, 1 DS tablet twice daily PO for 5-7 days —Ciprofloxacin, 500 mg PO twice daily for 5-7 days§ —Ofloxacin, 300 mg PO twionce once, then 500 mg PO daily for 6 days Pediatric (for severe cases, choose one, depending on suspected resistance pattern)**: —Ampicillin, 50-100 mg/kg/day PO in 4 divided doses —TMP/SMX, 8-12 mg/kg/day TMP PO in 2 divided doses —Cefotaxime, 75-100 mg/kg/day IV or IM in 3 or 4 divided doses —Ceftriaxone, 50-75 mg/kg/day IV or IM in 1 or 2 divided doses
Immunocompromised patients	Same, although treat for 14 days (or longer if relapse occurs)
Shigella species
Considerations	Resistance to TMP/SMX (59%) or to ampicillin (63%) is common and should be considered when prescribing therapy (see References: Replogle 2000, Lee 2001).
Recommended therapy‡
Immunocompetent patients	Adult (choose one): —Ciprofloxacin, 500 mg PO twice daily for 3 days§ —Ofloxacin, 300 mg PO twice daily for 3 days§ —Norfloxacin, 400 mg PO twice daily for 3 days§ —Nalidixic acid, 1 g PO daily for 5 days§ —Azithromycin, 500 mg PO once, then 250 mg PO for 4 days —TMP/SMX, 1 DS tablet PO twice daily for 3 days —Ceftriaxone also may be considered Pediatric (choose one, depending on resistance): —Ceftriaxone, 50-75 mg/kg/day IV or IM in 1 or 2 divided doses for 5 days —Ampicillin, 50-100 mg/kg/day PO in 4 divided doses for 5 days —TMP/SMX, 8-12 mg/kg/day TMP PO in 2 divided doses for 5 days
Immunocompromised patients	Same, although treat for 7-10 days
Vibrio cholerae
Considerations	—The cornerstone of therapy for cholera remains adequate rehydration (see References: Shears 2001). —Only culture-confirmed cases should be treated with antimicrobial agents.
Recommended therapy‡
Immunocompetent patients	Adult (for severe cases, choose one): —Doxycycline, 300 mg PO as single dose —Tetracycline, 500 mg PO 4 times daily for 3 days —TMP/SMX, 1 DS tablet PO twice daily for 3 days —Ciprofloxacin, 1 g PO as a single dose§ Pediatric (for severe cases, choose one): —Doxycycline, 6 mg/kg (maximum 300 mg) PO as single dose (generally should not be given to patients <8 yr of age, but in severe cases, benefits may offset risk of staining developing teeth) —Tetracycline, 50 mg/kg/day (maximum 2 g/day) PO in 4 divided doses for 3 days (generally should not be given to patients <8 yr of age, but in severe cases, benefits may offset risk of staining developing teeth) —TMP/SMX, 8 mg/kg/day TMP PO in 2 divided doses for 3 days —Erythromycin, 40 mg/kg/day (maximum 1 g) PO in 2-4 divided doses for 3 days
Immunocompromised patients	Same
Yersinia enterocolitica
Considerations	—Iron-overload states predispose to Yersinia infection; deferoxamine therapy should be withheld for patients on such therapy. —Antibiotics are often not needed for uncomplicated gastroenteritis in adult patients. —According to AAP, benefit from antibiotic therapy for patients with enterocolitis, mesenteric adenitis, or pseudoappendicitis syndrome has not been established; one recent study supported use of cefotaxime for children with bacteremia (see References: Abdel-Haq 2000).
Recommended therapy‡
Immunocompetent patients	Adult (for severe cases, choose one): —Gentamicin, 5 mg/kg/day IV in 3 divided doses —Cefotaxime, 1 to 2 gm IV 3 times daily —Consider use of a fluoroquinolone§ Pediatric (for severe cases, choose one): —Cefotaxime, 75-100 mg/kg/day IV or IM in 3 or 4 divided doses (higher doses [150-200 mg/kg/day in 3 or 4 divided doses] may be used —Gentamicin 2 mg/kg/dose IV 3 times daily
Immunocompromised patients	For severe cases: An aminoglycoside or combination therapy using at least two of the following: doxycycline, aminoglyoside, TMP/SMX, or a fluoroquinolone§
Abbreviations: AAP, American Academy of Pediatrics; CDC, Centers for Disease Control and Prevention; DS, double-strength; HIV, human immunodeficiency virus; HUS, hemolytic uremic syndrome (triad of hemolytic anemia, thrombocytopenia, and renal impairment); IM, intramuscularly; IV, intravenously; PO, orally; TMP/SMX, trimethoprim-sulfamethoxazole. Foodborne agents not included in this table generally require supportive care without use of antibiotics. †Treatment of systemic illnesses caused by foodborne agents are not covered in this table. ‡Adapted from Guerrant 2001 and AAP: The management of acute gastroenteritis in young children (see References); pediatric doses are intended for children beyond the newborn period (ie, >4 wk of age). §Fluoroquinolones are not recommended for use in children younger than 18 yr owing to risk of arthropathy. *According to AAP, duration of therapy for children depends on site of infection, host, and clinical response.

Clinical Considerations

Before prescribing treatment for an acute gastrointestinal illness, clinicians should question patients about symptoms and associated epidemiologic risk factors (see References: Guerrant):

Travel to a developing area
Child-care attendance or employment
Consumption of unsafe foods (eg, raw or undercooked meat, eggs, or shellfish, unpasteurized milk)
Swimming in an untreated body of water (lake, river)
Recent contact with animals (visiting a farm or petting zoo, contact with reptiles)
Knowledge of other ill persons (which may suggest a common-source outbreak)
Recent or regular medications (particularly antibiotics)
Underlying medical condition (particularly HIV infection)
Occupation as a food handler or caregiver
Receptive anal intercourse or oral-anal contact

Common epidemiologic associations are shown in the table below.

Common Epidemiologic Associations for Foodborne Pathogens
Epidemiologic Feature	Pathogens
Travel to a developing area	—Enterotoxigenic Escherichia coli —Salmonella (including S typhi) —Shigella (including S dysenteriae) —Campylobacter —Vibrio cholerae (rare in travelers) —Entamoeba histolytica
Consumption of raw or undercooked foods of animal origin*	—Salmonella (undercooked eggs, meat, chicken) —Campylobacter (undercooked chicken) —E coli O157:H7 (undercooked beef, especially hamburger) —Toxoplasma gondii (undercooked pork, lamb, venison) —Trichinella spiralis (undercooked meat) —Yersinia enterocolitica (undercooked pork, unpasteurized milk)
Exposure to untreated water	—Shigella (lakes contaminated with human feces) —E coli O157:H7 (lakes contaminated with human feces) —Cryptosporidium (water contaminated with human or animal feces, including swimming pools, since oocytes are resistant to chlorine) —Giardia (water contaminated with animal feces) —Agent of Brainerd diarrhea
Contact with animals	—Cryptosporidium (petting zoos) —Salmonella (reptiles) —E coli O157:H7 (farm animals)
Consumption of undercooked or raw shellfish	—Vibrio species —Hepatitis A virus —Caliciviruses, including Norwalk/Norwalk-like viruses
Consumption of ready-to-eat deli meats	Listeria monocytogenes
Consumption of food contaminated by infected food handlers	—Hepatitis A virus —Caliciviruses, including Norwalk/Norwalk-like viruses —Rotavirus —Salmonella —Shigella —Staphylococcus aureus
Recent antibiotic exposure	—Clostridium difficile —Salmonella† —Campylobacter†
*Other food items may become contaminated during preparation through contact with raw foods of animal origin. For example, vegetables may become contaminated when a food handler cuts raw chicken on a cutting board and then chops raw vegetables on the same cutting board without thoroughly cleaning it. †Several studies have shown an association between prior antibiotic use and infection with these agents (regardless of whether strain is resistant), although mechanism is not clear (see References: Effler 2001, Schwartz 2002).

Stool culture should be considered in outpatients with an acute diarrheal illness lasting more than 1 day, especially if the illness is part of a suspected outbreak or if the illness is accompanied by:

Fever
Bloody stools
Systemic illness
Recent use of antibiotics
Child-care attendance
Recent hospitalization
Dehydration

Parasitic infections should be considered in outpatients with gastroenteritis lasting more than 7 days:

Giardia lamblia
Cryptosporidium parvum
Cyclospora cayetanensis
Isospora belli

References

AAP. Isosporiasis. In: Pickering LK, ed. 2000 Red Book: Report of the Committee on Infectious Diseases. Ed 25. Elk Grove Village, IL: American Academy of Pediatrics, 2000:359-60

AAP. The management of acute gastroenteritis in young children. Pediatrics 1996;97(3) [Full text]

AAP. Salmonella infections. In: Pickering LK, ed. 2000 Red Book: Report of the Committee on Infectious Diseases. Ed 25. Elk Grove Village, IL: American Academy of Pediatrics, 2000:501-6

Abdel-Haq NM, Asmar BI, Abuhammour WM, Brown WJ. Yersinia enterocolitica infection in children. Pediatr Infect Dis J 2000;19(10):954-8 [Abstract]

Allos BM. Campylobacter jejuni infections: update on emerging issues and trends. Clin Infect Dis 2001 Apr 15;32(8):1201-6 [Abstract]

Carr A, Marriott D, Field A, et al. Treatment of HIV-1-associated microsporidiosis and cryptosporidiosis with combination antiretroviral therapy. Lancet 1998;351(9098):256-61 [Abstract]

CDC. Outbreak of multidrug-resistant Salmonella Newport—United States, January-April 2002. MMWR 2002;51(25);545-8 [Full text]

Chen XM, Keithly JS, Paya CV, et al. Cryptosporidiosis. N Engl J Med 2002;346(22):1723-30

Chiu CH, Wu TL, Su LH, et al. The emergence in Taiwan of fluoroquinolone resistance in Salmonella enterica serotype choleraesuis. N Engl J Med 2002;346(6):413-9 [Abstract]

Dunn EF, Fey PD, Kludt P, et al. Emergence of domestically acquired ceftriaxone-resistant Salmonella infections associated with AmpC beta-lactamase. JAMA 2000;284(24):3151-6 [Abstract]

Effler P, Ieong MC, Kimura A, et al. Sporadic Campylobacter jejuni infections in Hawaii: associations with prior antibiotic use and commercially prepared chicken. J Infect Dis 2001 Apr 1;183(7):1152-5 [Abstract]

Engberg J, Aarestrup FM, Taylor DE, et al. Quinolone and macrolide resistance in Campylobacter jejuni and C coli: resistance mechanisms and trends in human isolates. Emerg Infect Dis 2001;7(1):24-34 [Full text]

Guerrant RL, Van Gilder T, Steiner TS, et al. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis 2001 Feb 1;32(3):331-50 [Full text]

Herikstad H, Hayes, P, Mokhtar M, et al. Emerging quinolone-resistant Salmonella in the United States. Emerg Infect Dis 1997;3(3):371-2 [Full text]

Hewitt RG, Yiannoutsos CT, Higgs ES, et al. Paromomycin: no more effective than placebo for treatment of cryptosporidiosis in patients with advanced human immunodeficiency virus infection. AIDS Clinical Trial Group. Clin Infect Dis 2000;31(4):1084-92 [Abstract]

Lee JC, Oh JY, Kim KS, et al. Antimicrobial resistance of Shigella sonnei in Korea during the last two decades. APMIS 2001 Mar;109(3):228-34 [Abstract]

Miller JR. Decreasing cryptosporidiosis among HIV-infected persons in New York City, 1995-1997. J Urban Health 1998;75:601-2

Nash TE, Ohl CA, Thomas E, et al. Treatment of patients with refractory giardiasis. Clin Infect Dis 2001 Jul 1;33(1):22-8 [Abstract]

Petri WA Jr, Singh U. Diagnosis and management of amebiasis. Clin Infect Dis 1999 Nov;29(5):1117-25 [Full text]

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Ribot EM, Wierzba RK, Angulo FJ, et al. Salmonella enterica serotype typhimurium DT104 isolated from humans, United States, 1985,1990, and 1995. Emerg Infect Dis 2002;8(4):387-91 [Full text]

Rossignol JF, Ayoub A, Ayers MS. Treatment of diarrhea caused by Cryptosporidium parvum: a prospective randomized, double-blind, placebo-controlled trial of nitazoxanide. J Infect Dis 2001 Jul 1;184(1):103-6 [Abstract]

Rossignol JF, Hidalgo H, Feregrino M, et al. A double-'blind' placebo-controlled study of nitazoxanide in the treatment of cryptosporidial diarrhoea in AIDS patients in Mexico. Trans R Soc Trop Med Hyg 1998 Nov-Dec;92(6):663-6 [Abstract]

Schwartz MN. Human disease caused by foodborne pathogens of animal origin. Clin Infect Dis 2002 Jun 1;34(suppl 3):S111-S22 [Abstract]

Shears P. Recent developments in cholera. Curr Opin Infect Dis 2001;14:553-8 [Abstract]

Smith KE, Besser JM, Hedberg CW, et al. Quinolone-resistant Campylobacter jejuni infections in Minnesota, 1992-1998: investigation team. N Engl J Med 1999;340(20):1525-32 [Abstract]

Threlfall EJ, Ward LR, Skinner JA, et al. Ciprofloxacin-resistant Salmonella typhi and treatment failure. Lancet 1999 May 8;353(9164):1590-1

Verdier RI, Fitzgerald DW, Johnson WD Jr, et al. Trimethoprim-sulfamethoxazole compared with ciprofloxacin for treatment and prophylaxis of Isospora belli and Cyclospora cayetanensis infection in HIV-infected patients: a randomized, controlled trial. Ann Intern Med 2000;132(11):885-8 [Abstract]

White DG, Zhao S, Simjee S, et al. Antimicrobial resistance of foodborne pathogens. Microbes Infect 2002;4:405-12 [Abstract]

Wong CS, Jelacic S, Habeeb RL, et al. The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections. N Engl J Med 2000;342(26):1930-6 [Abstract]


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