(http://www.ugm.ac.

id)

CLINICAL OVERVIEW

Food Poisoning, Bacterial

Fort, Glenn G., MD, MPH
Released January 1, 2023.

Basic Information

Definition
Food poisoning is an illness caused by ingestion of food contaminated by bacteria
and/or bacterial toxins. A foodborne disease outbreak is defined as two or more cases
of a similar illness resulting from ingestion of a common food.

Synonyms
Enterotoxin-poisoning

Epidemic vomiting disease

 ICD-10CM CODE

A05.9 Bacterial foodborne intoxication, unspecified

Epidemiology & Demographics

Incidence (In U.S.)

• CDC estimates that each yr one in six Americans will experience a foodborne illness.

• Approximately 800 foodborne disease outbreaks are reported in the U.S. each yr,
accounting for approximately 15,000 illnesses, 800 hospitalizations, and 20 deaths.
Outbreak-associated foodborne illnesses are only a small subset of the estimated 9.4
million foodborne illnesses that occur annually in the U.S.

• Majority of identifiable causes are bacterial, although more than 250 known diseases
can be transmitted through food.

Predominant Age
Varies with specific agent

Peak Incidence
Varies with specific organism

• Summer: Staphylococcus aureus, Salmonella, Shigella spp.

• Summer and fall: Clostridium botulinum, Vibrio parahaemolyticus

• Spring and fall: Campylobacter jejuni

• Winter: Clostridium perfringens, Yersinia enterocolitica

Neonatal Infection
Rare but severe with Shigella and Salmonella spp.

Physical Findings & Clinical Presentation

• Any combination of GI symptoms and fever. Orthostatic pulse and blood pressure
changes should be noted

• Specific organisms suspected on the basis of the incubation period and

predominant symptoms (Table 1 (https://www-clinicalkey-
com.ezproxy.ugm.ac.id/#!/content/derived_clinical_overview/76-s2.0-B9780323755733003590#t0010)),
although a great deal of overlap exists

1. Short incubation period (1-6 hr): Involve the ingestion of preformed toxin;
noninvasive.

a. S. aureus: Nausea, profuse vomiting, and abdominal cramps common;

diarrhea possible, but fever uncommon; usually resolves within 24 hr;
foods implicated in outbreaks include meats, mayonnaise, and cream
pastries.

b. B. cereus: Two forms, a short incubation (emetic) form (characterized by

vomiting and abdominal cramps in virtually all patients, diarrhea in one
third of patients, fever uncommon) and a long incubation (diarrheal) form;
illness usually mild, resolves within 12 hr; unrefrigerated rice most often
implicated as vehicle. Other sources include gravy, meats, stews, vanilla,
and sauces.

2. Moderate incubation period (8-16 hr): Involves the in vivo production of toxin;
noninvasive.
 a. C. perfringens: Severe crampy abdominal pain and watery diarrhea
common; fever and vomiting unlikely; symptoms usually resolving within
24 hr; outbreaks invariably related to cooked meat or poultry that is allowed
to cool without refrigeration; most cases in the fall and winter months. C.
perfringens is the third most common cause of foodborne illness in the
United States.

b. B. cereus: Diarrheal (or long incubation) form most commonly beginning

with diarrhea, abdominal cramps, and occasionally vomiting; fever
uncommon; usually resolves within 24 hr; the responsible food is usually
fried rice.

3. Long incubation period (>16 hr): Some toxin-mediated, some invasive.

TABLE 1
Foodborne Disease Agents and Clinical Presentation
From Cherry JD et al: Feigin and Cherry’s pediatric infectious diseases, ed 8, Philadelphia, 2019, Elsevier.

Usual Causative Clinical Illness Epidemiologic and

Incubation Agent Laboratory
Periods Fever Diarrhea Vomiting Diagnosis

5 min-6 hr Chemical or toxin Rare Occasional Common Demonstration of

(usually <3 toxin or chemical from
hr) food or epidemiologic
incrimination of food

1-6 hr Staphylococcus Rare Occasional Profuse Isolation of organisms

(usually <1 aureus in food
hr) (>105/g)/vomitus/stool;
enterotoxin
detection of
enterotoxin in food

Bacillus cereus Rare Occasional Profuse Isolation of organisms

emetic toxin in food
(>105/g)/vomitus/stool

6-24 hr Clostridium Rare Typical Occasional Isolation of organisms

perfringens or toxin from food
enterotoxin (105/g) or stools of ill
persons,
 B. cereus Rare Typical Occasional epidemiologic
enterotoxin incrimination of food;
detection of
enterotoxin in food

12-72 hr Clostridium Clinical Constipation Isolation of organism

botulinum syndrome more or toxin from food
compatible common (105/g) or stools;
with demonstration of
botulism toxin in serum or food

16-96 hr Shigella Common Typical, Occasional Isolation of organism

often bloody from clinical
specimens from two
Nontyphoidal Common Typical Occasional or more ill persons;
Salmonella isolation of organism
from
Enteroinvasive E. Common Typical, may Occasional epidemiologically
coli (EIEC) be bloody implicated food

Enteropathogenic Occasional Typical Occasional

E. coli (EPEC)

Enterotoxigenic Rare Typical Rare

E. coli (ETEC)

Vibrio Occasional Typical Occasional

parahaemolyticus;
V. cholerae
enterotoxin

1-3 days Caliciviruses Occasional Typical Common Antigen detection

(noroviruses) (enzyme
Rotavirus immunoassay) in
stool; immune
electron microscopy of
stool; detection of viral
RNA in stool or
vomitus by PCR

1-10 days Yersinia Uncommon Typical, Uncommon Isolation of organisms

severe from food or clinical
abdominal specimens of ill
pain persons

2-10 days Campylobacter Common Typical, Uncommon Isolation of organisms

jejuni often bloody from food or clinical
specimens of ill
persons

1-11 days Cryptosporidium Occasional Common Occasional Demonstration of

oocysts in stool or in
small bowel biopsy of
ill persons;
demonstration of
organism in
 epidemiologically
implicated food

Cyclospora Occasional Common Occasional Demonstration of

parasite in stool or in
small bowel biopsy of
ill persons;
demonstration of
organism in
epidemiologically
implicated food

Giardia Occasional Common Occasional Demonstration of

intestinalis parasite in stool or in
small bowel biopsy of
ill persons;
demonstration of
organism in
epidemiologically
implicated food

2 days- Bacillus anthracis Common Typical Frequent Isolation of organism

weeks from blood or
contaminated meat

1-7 days E. coli O157:H7 Uncommon Typical Frequent Isolation of organism

and other Shiga from food or stool or
toxin–producing identification of toxin
E. coli in stools of ill persons

3-60 days, Salmonella typhi Common Diarrhea or Uncommon Isolation of organisms

usually 7-14 constipation from food or clinical
specimens of ill
persons

7-21 days Brucella spp. Common Common Rare Isolation of organisms

from blood or bone
marrow culture of ill
persons; fourfold
increase in standard
agglutination titer
overall several weeks
or single titer 1:160 in
person with
compatible clinical
syndrome

1-4 wk Giardia lamblia Rare Common Rare Stool for ova and
parasite examination
enzyme immunoassay

2 days-8 wk Trichinella spiralis Common Common Common Serology, muscle

biopsy
PCR, Polymerase chain reaction; RNA, ribonucleic acid.

• Toxin-producing organisms include

1. C. botulinum: Should be considered when a diarrheal illness coincides with or
precedes paralysis; severity of illness related to the quantity of toxin ingested;
characteristic cranial nerve palsies progressing to a descending paralysis; fever
usually absent; usually associated with home-canned foods.

2. Enterotoxigenic E. coli (ETEC): Most common cause of travelers’ diarrhea; after

1- to 2-day incubation period, abdominal cramps and copious diarrhea occur;
vomiting and fever uncommon; usually resolves after 3 to 4 days; vehicle usually
unbottled water or contaminated salad or ice.

3. Enterohemorrhagic E. coli (EHEC): Can cause severe abdominal cramps and

watery diarrhea, which may eventually become bloody; bacteria (strain O157:H7)
are noninvasive; no fever; illness may be complicated by hemolytic-uremic
syndrome; associated with contaminated beef (especially hamburger),
unpasteurized milk or juice. Table 2 (https://www-clinicalkey-
com.ezproxy.ugm.ac.id/#!/content/derived_clinical_overview/76-s2.0-B9780323755733003590#t0015)
summarizes the various strains of diarrheagenic E. coli.

TABLE 2
Diarrheagenic Escherichia coli
From Feldman M et al: Sleisenger and Fordtran’s gastrointestinal and liver disease, ed 10, Philadelphia, 2016,
Elsevier.

Strains Pathogenic Mechanisms Persons Affected Clinical

Features

DAEC Diffuse adherence to Hep-2 Children in developing Watery diarrhea

cells countries (acute) and
persistent
diarrhea

EAEC Aggregative adherence to Hep- Children in developing Watery diarrhea

2 cells countries (acute) and
persistent
diarrhea

STEC Shiga toxins 1 and 2 Children and adults Watery diarrhea

O157:H7 Persons who ingest Bloody diarrhea
Non- contaminated food, (classic)
especially hamburger
 O157:H7 (outbreaks)
O104:H4∗

EIEC Epithelial cell invasion Children and adults Watery diarrhea

Dysentery

EPEC Attaching and effacing Children Watery diarrhea

Typical Bundle-forming pilus, (acute)
Atypical attachment and effacement Persistent
lesions or atypical adherence diarrhea
pattern

ETEC Heat-labile and/or heat-stable Children in developing Watery diarrhea

toxin countries; travelers
Adherence
DAEC, Diffusely adhering Escherichia coli; EAEC, enteroaggregative E. coli; EIEC, enteroinvasive E. coli;
EPEC, enteropathogenic E. coli; ETEC, enterotoxigenic E. coli; STEC, Shiga toxin–producing E. coli.

4. V. cholerae: Varies from a mild, self-limited illness to life-threatening cholera;

diarrhea, nausea and vomiting, abdominal cramps, and muscle cramps; no
fever; severe cases may progress to shock and death within hours of onset;
survivors usually have resolution of symptoms in 1 wk; U.S. cases are either
imported or result from ingestion of imported food.

• Invasive organisms include

1. Salmonella: Associated most often with nontyphoidal strains; incubation period

generally 12 to 48 hr; nausea, vomiting, diarrhea, and abdominal cramps typical;
fever possible; outbreaks of gastroenteritis related to contaminated poultry,
meat, and dairy products.

2. Shigella: Asymptomatic infection possible, but some with fever and watery
diarrhea that may progress to bloody diarrhea and dysentery; with mild illness,
usually self-limited, resolves in a few days; with severe illness, may develop
complications; transmission usually from person to person but can occur via
contaminated food or water.

3. C. jejuni: The most common foodborne bacterial pathogen; incubation period

is about 1 day, then a prodrome of fever, headache, and myalgias; intestinal
phase marked by diarrhea associated with fever, malaise, and abdominal pain;
diarrhea mild to profuse and bloody; usually resolves in about 7 days, but
relapse is possible; associated with undercooked meats and poultry,
unpasteurized dairy products, and drinking from freshwater streams.
 4. Y. enterocolitica and Y. pseudotuberculosis: Infrequent causes of enteritis in the
United States; children affected more often than adults; fever, diarrhea, and
abdominal pain lasting 1 to 3 wk; some with mesenteric adenitis that mimics
acute appendicitis; contaminated food or water is usually responsible.

5. V. parahaemolyticus: In the United States, most outbreaks in coastal states or on

cruise ships during the summer months; incubation period usually >1 day,
followed by explosive watery diarrhea in the majority of cases; nausea, vomiting,
abdominal cramps, and headache also common; fever less common; usually
resolves by 1 wk; related to ingestion of seafood.

6. Enteroinvasive E. coli (EIEC): A rare cause of disease in the United States; high
incidence of fever and bloody diarrhea; may resemble bacillary dysentery.

7. V. vulnificus: May cause serious, often fatal illness in persons with chronic liver
disease; GI symptoms usually absent, but fever, chills, hypotension, and
hemorrhagic skin lesions possible; patients with liver disease or at increased
risk of developing liver disease should avoid eating raw oysters.

Etiology
• Table 3 (https://www-clinicalkey-com.ezproxy.ugm.ac.id/#!/content/derived_clinical_overview/76-s2.0-
B9780323755733003590#t0020) describes pathogenic mechanisms in bacterial foodborne
disease.

TABLE 3
Pathogenic Mechanisms in Bacterial Foodborne Disease
From Mandell GL et al: Principles and practice of infectious diseases, ed 6, Philadelphia, 2005, Churchill
Livingstone.

Preformed Toxin Toxin Production Tissue Toxin Production and/or

in Vivo Invasion Tissue Invasion

Staphylococcus aureus Clostridium Campylobacter Vibrio parahaemolyticus

Bacillus cereus (short perfringens jejuni Yersinia enterocolitica
 incubation) B. cereus (long Salmonella
Clostridium incubation) Shigella
botulinum C. botulinum (infant Invasive E. coli
botulism)
Enterotoxigenic
Escherichia coli
Vibrio cholerae O1 or
O139
V. cholerae non-O1
Shiga toxin–
producing E. coli

• Classically categorized as either inflammatory (invasive) or noninflammatory.

1. Noninflammatory: B. cereus, S. aureus, C. botulinum, C. perfringens, V.

cholerae, enterotoxigenic E. coli (ETEC), and enterohemorrhagic E. coli (EHEC);
toxin-producing organisms that are noninvasive; fecal leukocytes are not seen.

2. Inflammatory: Campylobacter, enteroinvasive E. coli (EIEC), Salmonella,

Shigella, V. parahaemolyticus, and Yersinia; cause disease by invasion of
intestinal tissue; fecal leukocytes are seen.

Diagnosis

Differential Diagnosis
Gastroenteritis caused by viruses (Norwalk, Noro, or rotavirus), parasites (Amoeba
histolytica, Giardia lamblia), or toxins (ciguatoxins, mushrooms, heavy metals)

Laboratory Tests
• Watchful waiting is often the most appropriate option and ancillary testing is usually
not necessary.
• In severe or persistent cases, stool test for fecal leukocytes may help narrow the
differential diagnosis.

1. Send stool for culture and for ova and parasites.

2. Send stool for C. difficile toxin in patients with current or recent antibiotic use.

3. Note: Some pathogens are not identified on routine stool culture; laboratory
should be advised if Yersinia, C. botulinum, Vibrio, or enterohemorrhagic E.
coli (O157:H7) are suspected.

4. Finding B. cereus, C. perfringens, or E. coli in stool is of little value, because

these may be part of the normal bowel flora.

5. Stool cultures are positive in less than 40% of cases.

6. Newer techniques such as polymerase chain reaction (PCR) testing provide a

more rapid and reliable determination of specific pathogens.

• If botulism suspected, send food, serum, and stool for toxin assay.

• Blood cultures should be considered for all febrile patients.

• Consider toxic megacolon (identified on plain abdominal sonography).

• Consider sigmoidoscopy to obtain tissue and histology in hospitalized patients with

bloody diarrhea.

• Consider lactoferrin measurement if an inflammatory etiology is suspected.

Treatment

Nonpharmacologic Therapy
Adequate rehydration is the mainstay of therapy.
Acute General Rx
• Most cases of acute infectious diarrhea are viral and antibiotics are not indicated.

• Gastroenteritis caused by the following bacterial organisms requires no

antimicrobial treatment: B. cereus, S. aureus, C. perfringens, V. parahaemolyticus,
Yersinia, and enterohemorrhagic and enteroinvasive E. coli.

• The usual cause of travelers’ diarrhea is enterotoxigenic E. coli. Although usually a

self-limited illness, antibiotics can shorten the course in patients with fever or
dysentery.

1. Azithromycin 1000 mg in a single oral dose or

2. SMX/TMP one DS tab bid for 3 days or

3. Ciprofloxacin 500 mg PO bid for 3 days

• The mainstay of therapy for cholera is fluid replacement. Antibiotics should be given
to decrease shedding and duration of illness.

1. Doxycycline 300 mg in a single dose or 100 mg PO bid for 3 days

2. SMX/TMP 1 DS tab bid for 3 days

• Treatment is not indicated for Salmonella gastroenteritis. Patients who are at high
risk of developing bacteremia may be treated for 48 to 72 hr (see “Salmonellosis”).

• Although shigellosis tends to be a self-limited illness, antibiotics shorten the course

of illness and may limit transmission of the illness (see “Shigellosis”).

• Those with moderate or severe Campylobacter diarrhea may benefit from treatment.

1. Azithromycin 500 mg qd for 3 days or

2. Erythromycin 500 mg PO qid for 5 days or

3. Ciprofloxacin 500 mg PO bid for 5 days

• V. vulnificus sepsis should be treated with

Outline
1. Doxycycline 100 mg IV bid for 2 wk

2. Ceftazidime 2 g IV q8h for 2 wk

• For suspected botulism, antitoxin should be administered early (see “Botulism”).

• Table 4 (https://www-clinicalkey-com.ezproxy.ugm.ac.id/#!/content/derived_clinical_overview/76-s2.0-
B9780323755733003590#t0025) summarizes antibiotic therapy for nonsevere infections with
common bacterial enteropathogens in immunocompetent adults.

TABLE 4
Antibiotic Therapy for Nonsevere Infections With Common Bacterial Enteropathogens in Immunocompetent
Adults
From Feldman M et al: Sleisenger and Fordtran’s gastrointestinal and liver disease, ed 10, Philadelphia, 2016,
Elsevier.

Organism Recommended Alternative

Antibiotic(s) Antibiotic(s)

Shigella Species

Shigella infection (non- dysenteriae; for Shigella Ciprofloxacin 500 Azithromycin

dysenteriae type 1, see text) mg twice daily (or 500 mg-1 g
levofloxacin 500 mg daily × 3-5 days
daily) × 3 days TMP/SMX 160
mg/800 mg
twice daily, if
sensitive, × 3
days

Salmonella Species

Enterocolitis, uncomplicated Not usually Can consider in

recommended (see areas of high
text) fluoroquinolone
quinolone
Typhoid and enteric fevers ∗ (https://www-clinicalkey- Ciprofloxacin 500 resistance;
com.ezproxy.ugm.ac.id/#!/content/derived_clinical_overview/76- mg twice daily (or azithromycin 1
ofloxacin 400 mg g daily × 5 days
s2.0-B9780323755733003590#tbl4fn1)
twice daily) × 7-14
days
Ceftriaxone 2-3 g IV
 daily × 7-14 days

Campylobacter Species

Campylobacter jejuni Not usually required Azithromycin

Ciprofloxacin 500 500 mg-1 g × 3-
mg twice daily × 3 5 days
days

Yersinia enterocolitica

Enterocolitis, uncomplicated Not usually required An

aminoglycoside
(parenteral)
tetracycline 500
mg 4 times daily
× 5 days
TMP/SMX 160
mg/800 mg
twice daily × 5
days
Ciprofloxacin
500 mg twice
daily × 5 days
Doxycycline 100
mg twice daily ×
5 days

Escherichia coli † (https://www-clinicalkey-com.ezproxy.ugm.ac.id/#!/content/derived_clinical_overview/76-

s2.0-B9780323755733003590#tbl4fn2)

Enterotoxigenic Endemic disease; Azithromycin

usually self-limited, 500 mg-1 g
supportive care (see daily × 3-5 days
text). Travelers’ TMP/SMX 160
diarrhea: mg/800 mg
Ciprofloxacin 500 twice daily, if
mg twice daily × 3 sensitive, × 3
days days
Rifaximin 200 mg 3
times daily × 3 days

Shiga toxin–producing Unclear if antibiotics

are effective; may be
harmful

Vibrio Species

Vibrio cholerae Doxycycline 300 mg Ciprofloxacin 1

× 1 dose g × 1 dose
Azithromycin 1
g × 1 dose
Tetracycline 500
mg every 6 hr ×
3 days
 Vibrio parahaemolyticus Usually not required; As for V.
no controlled trials cholerae
TMP/SMX, Trimethoprim/sulfamethoxazole. Note: All antibiotics are administered orally unless otherwise indicated.
Recommendations are given for treatment of mild/moderate infections only. Treatments for complicated infections
or severely ill, bacteremic, or immunocompromised patients are not listed above and may differ from treatments
for mild disease.

Chronic Rx
Patients with Salmonella infections may become carriers and may require treatment
(see “Salmonellosis”).

Disposition
• Most infections are self-limited and do not require therapy.

• In immunocompromised host or patient with underlying disease, serious

complications are possible.

• Postinfectious syndromes are important with some infections.

1. Reiter syndrome: Salmonella, Shigella, Campylobacter, Yersinia spp.; more

common in genetically susceptible host (HLA-B27+)

2. Guillain-Barré syndrome: Campylobacter spp.

Referral
If more than a mild illness

Pearls & Considerations

Comments
• Grossly underreported and undiagnosed

• All cases to be reported to the local health department

• Table E5 (https://www-clinicalkey-com.ezproxy.ugm.ac.id/#!/content/derived_clinical_overview/76-s2.0-
B9780323755733003590#t0030) summarizes control and prevention measures of foodborne
diseases

TABLE E5
Control and Prevention of Foodborne Diseases
From Bennett JE et al: Mandell, Douglas, and Bennett’s principles and practice of infectious diseases, ed 8,
Philadelphia, 2015, Saunders.

General Recommendations for All Persons

• Thoroughly cook raw food from animal sources, such as beef, pork, poultry, fish, and eggs, to
temperatures that eliminate most pathogens. ∗ (https://www-clinicalkey-
com.ezproxy.ugm.ac.id/#!/content/derived_clinical_overview/76-s2.0-B9780323755733003590#tbl5fn1)

• Wash raw fruits and vegetables before eating.

• Keep uncooked meats separate from fruits, vegetables, cooked foods, and ready-to-eat foods.

• Do not thaw meat, poultry, or fish on the counter (instead, thaw in a refrigerator, in cold water,
or in a microwave oven).

• Wash hands before, during, and after preparing food and before eating food.

• Wash knives, other utensils, and cutting boards after handling uncooked foods.

• Keep refrigerators set to below 40° F and freezers set to 0° F or lower and verify with a
thermometer.

• Refrigerate perishable foods within 2 hr (or within 1 hr if left out at temperatures >90°F).
• Read and follow all cooking and storage instructions on food product packaging. This is
especially important for foods prepared in microwave ovens because these ovens heat foods
unevenly. Even foods that may appear ready to eat may require thorough cooking.

• Persons with diarrhea or vomiting possibly caused by an infectious agent should not prepare
foods for others.

• Keep all animals, including reptiles and amphibians, away from surfaces where foods or drinks
are prepared.

• Do not drink unpasteurized (raw) milk or eat foods made from unpasteurized milk. (Exception:
Hard cheeses made from raw milk that have been aged >60 days are generally safe to eat.)

• Do not eat home-canned foods that were not known to be adequately heat processed during
canning.

Recommendations for Persons at High Risk, Such as Pregnant Women and People With Weakened
Immune Systems, in Addition to the Recommendations Listed Above

Measures to Prevent a Variety of Bacterial Infections

• Do not eat uncooked sprouts.

• Do not drink prepackaged juice or juice-containing beverages that have not been processed to
reduce or eliminate microbial contamination (e.g., by pasteurization).

Listeriosis Prevention Measures

• Do not eat soft cheeses, such as feta, Brie, and Camembert; blue-veined cheeses; and Mexican-
style cheeses, such as queso blanco, queso fresco, and panela, unless the package has a label
that clearly states that the cheese is made from pasteurized milk.

• Do not eat refrigerated pâtés or meat spreads. Canned or shelf-stable pâtés and meat spreads
are safe to eat.

• Do not eat refrigerated smoked seafood unless it is contained in a cooked dish, such as a
casserole. Refrigerated smoked seafood, such as salmon, trout, whitefish, cod, tuna, and
mackerel, is most often labeled as “nova-style,” “lox,” “kippered,” “smoked,” or “jerky.” The fish
is found in the refrigerator section or sold at delicatessen counters of grocery stores and
delicatessens. Canned or shelf-stable smoked seafood is safe to eat.

• Do not eat hot dogs, luncheon meats, or delicatessen meats unless they are reheated until
steaming hot.

• Avoid getting fluid from hot dog packages on other foods, utensils, and food preparation
surfaces, and wash hands after handling hot dogs, luncheon meats, and delicatessen meats.

Salmonellosis Prevention Measures

 • Choose pasteurized eggs.

Vibriosis, Toxoplasmosis, and Norovirus Prevention Measures

• Do not eat raw or lightly steamed oysters, clams, or other raw shellfish (especially important for
patients with liver disease).

More food safety information can be found at www.foodsafety.gov/keep/index.html

(http://www.foodsafety.gov/keep/index.html).

Suggested Readings
Braden C.R., Tauxe R.V.: Emerging trends in foodborne diseases. Infect Dis Clin North Am 2013;
27: pp. 517-533.

Dewey-Mattia D., et al.: Surveillance for foodborne disease outbreaks—United States 2009-2015.
MMWR Surveill Summ 2018; 67 (10): pp. 1-11.

Donnenberg M.S., Narayanan S.: How to diagnose a foodborne illness. Infect Dis Clin North Am
2013; 27: pp. 535-554.

DuPont H.L., et al.: Acute infectious diarrhea in immunocompetent adults. N Engl J Med 2014;
370: pp. 1532-1540.

Kalyoussef S., Feja K.N.: Foodborne illnesses. Adv Pediatr 2014; 61: pp. 287-312.

Switaj T.L., et al.: Diagnosis and management of foodborne illness. Am Fam Physician 2015; 92:
pp. 358-365.

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