title: The epidemiology of travelers' diarrhea in Incirlik, Turkey: a region with a predominance of heat-stabile toxin producing enterotoxigenic Escherichia coli.
abstract: This study evaluated travelers' diarrhea among US military personnel on short-term deployment to Incirlik Air Base, Turkey, from June through September 2002. Upon reporting for care for travelers' diarrhea, subjects were enrolled into the study and completed a series of questionnaires and provided stool specimens for pathogen identification and antimicrobial susceptibility testing. Fifty-three percent of the 202 participating subjects had a pathogen isolated from their stool. Enterotoxigenic Escherichia coli (ETEC) was the predominant pathogen (41%), followed by Campylobacter spp. (12%). The most common ETEC phenotype recovered was stable toxin (ST) CS6 (47% of all ETEC). Most (91.1%) of the cases presented with water diarrhea regardless of isolated pathogen. However, there were some differences in nongastrointestinal symptoms among subjects with Campylobacter spp. All illnesses were well managed with antibiotics with or without loperamide with a median time to the last unformed stool of 9 h (interquartile range, 1-32 h). We found no food or environmental factors associated with a differential risk of infection with a specific pathogen. Travelers' diarrhea among a US military population in and around Incirlik, Turkey, can commonly be attributed to ETEC and Campylobacter spp. The high proportion of ST-only-producing CS6 ETEC in this region highlights the pathogen's worldwide diversity. Future studies of travelers' diarrhea in this population should adapt more novel microbiologic techniques such as polymerase chain reaction and enhanced culture methods to increase the likelihood of identifying pathogenic E. coli.
authors.affiliation: Enteric Diseases Department, Naval Medical Research Center, Silver Spring, MD 20910-7500, USA. chad.porter@med.navy.mil
authors.forename: Chad K
authors.initials: CK
authors.lastname: Porter
authors.forename: Mark S
authors.initials: MS
authors.lastname: Riddle
authors.forename: David R
authors.initials: DR
authors.lastname: Tribble
authors.forename: Shannon D
authors.initials: SD
authors.lastname: Putnam
authors.forename: David M
authors.initials: DM
authors.lastname: Rockabrand
authors.forename: Robert W
authors.initials: RW
authors.lastname: Frenck
authors.forename: Patrick
authors.initials: P
authors.lastname: Rozmajzl
authors.forename: Edward
authors.initials: E
authors.lastname: Kilbane
authors.forename: Ann
authors.initials: A
authors.lastname: Fox
authors.forename: Richard
authors.initials: R
authors.lastname: Ruck
authors.forename: Matthew
authors.initials: M
authors.lastname: Lim
authors.forename: James
authors.initials: J
authors.lastname: Johnston
authors.forename: Emmett
authors.initials: E
authors.lastname: Murphy
authors.forename: John W
authors.initials: JW
authors.lastname: Sanders
mesh_terms: D000328:Adult; D000890:Anti-Infective Agents / Q000627:therapeutic use; D000930:Antidiarrheals / Q000627:therapeutic use; D001427:Bacterial Toxins / Q000096:biosynthesis* / Q000235:genetics; D016009:Chi-Square Distribution; D003967:Diarrhea / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D054307:Enterotoxigenic Escherichia coli / Q000187:drug effects / Q000235:genetics / Q000302:isolation & purification / Q000378:metabolism*; D004768:Enterotoxins / Q000096:biosynthesis* / Q000235:genetics; D029968:Escherichia coli Proteins; D005260:Female; D006801:Humans; D008297:Male; D008826:Microbial Sensitivity Tests; D008889:Military Personnel; D011446:Prospective Studies; D012307:Risk Factors; D014195:Travel / Q000706:statistics & numerical data*; D014421:Turkey / Q000453:epidemiology
chemical_list: D000890:Anti-Infective Agents; D000930:Antidiarrheals; D001427:Bacterial Toxins; D004768:Enterotoxins; D029968:Escherichia coli Proteins; C034151:heat stable toxin (E coli)