Foodborne Illness.

• •Onset of vomiting within hours of eating leftover or unrefrigerated food (suggests preformed toxin)
• •Cluster of similar illness among people who shared a meal — outbreak pattern warranting public health notification
• •Travel to a developing country in the prior 2 weeks with new-onset diarrhea (traveler's diarrhea, often E. coli)
• •Pregnancy with new diarrhea, fever, or flu-like illness after eating soft cheese, deli meat, or refrigerated pâté — listeria evaluation
• •Bloody diarrhea after eating undercooked ground beef or unpasteurized dairy — possible STEC infection

Most foodborne illness is mild, self-limited, and managed clinically without laboratory testing. Stool testing is recommended for severe disease (dehydration, severe abdominal pain), dysentery (bloody diarrhea), prolonged illness over 7 days, fever over 38.5°C, immunocompromise, recent travel, occupational risk (food handler, healthcare worker, daycare worker), suspected outbreak, or extremes of age. Modern stool diagnosis increasingly uses multiplex PCR panels (BioFire FilmArray GI panel, Verigene GI) that simultaneously detect 20+ bacterial, viral, and parasitic pathogens with results in hours. Stool culture remains essential for antibiotic susceptibility, public health subtyping, and outbreak investigation in suspected bacterial cases. Stool antigen tests are available for norovirus, rotavirus, Cryptosporidium, and Giardia. Routine ova-and-parasite microscopy has been largely replaced by antigen and PCR testing in high-income settings. Specific clinical scenarios trigger pathogen-directed testing: bloody diarrhea warrants screening for STEC (including non-O157), Shigella, and Campylobacter; fever with hepatosplenomegaly in a returned traveler warrants blood cultures for typhoidal Salmonella; pregnancy with febrile gastroenteritis warrants Listeria blood cultures; flaccid paralysis warrants botulism serum and stool toxin assay. Imaging is reserved for complications: abdominal CT for suspected perforation or ileus, ultrasound or CT for suspected hemolytic uremic syndrome (renal findings). Lactate, CBC, electrolytes, and renal function guide severity assessment. Outbreak investigation involves case-finding, exposure history (specific meals, ingredients, restaurants), environmental sampling, and public health reporting.

• ✓Oral rehydration solution (WHO ORS or commercial equivalent, sipped frequently)
• ✓Azithromycin (1 g single dose, or 500 mg daily for 3 days) for traveler's diarrhea and Campylobacter
• ✓Ciprofloxacin (500 mg twice daily for 3-5 days) or levofloxacin for severe bacterial gastroenteritis
• ✓Loperamide (4 mg initial dose, then 2 mg after each loose stool, max 16 mg/day) for adult watery diarrhea

Bacterial contamination of food at any stage from farm to fork

Most US foodborne disease burden traces to cross-contamination from raw meat to ready-to-eat foods, inadequate cooking temperatures, and improper refrigeration in food preparation chains. Salmonella, Campylobacter, and pathogenic E. coli are the leading bacterial culprits.

Norovirus transmission through infected food handlers

Norovirus is the single most common cause of foodborne illness in the US (over 5 million cases per year, per CDC). A food handler with active or recent illness can shed virus on bare-handed contact with ready-to-eat foods. Heat-stable and resistant to common disinfectants.

Preformed bacterial toxins in food stored at room temperature

Staphylococcus aureus and Bacillus cereus produce heat-stable enterotoxins when foods are left at room temperature long enough to support bacterial growth. Reheating destroys the bacteria but not the toxin — so reheated leftovers can still cause illness.

Undercooked or raw animal products

Raw or undercooked ground beef carries Shiga-toxin-producing E. coli; raw poultry carries Salmonella and Campylobacter; raw eggs carry Salmonella Enteritidis; raw shellfish carry Vibrio and norovirus. Internal cooking temperatures (165°F poultry, 160°F ground beef, 145°F whole cuts) eliminate most pathogens.

Unpasteurized dairy and juices

Raw milk, raw cheese, and unpasteurized cider/juice can harbor Salmonella, Listeria, Campylobacter, E. coli O157:H7, and Brucella. CDC tracks outbreaks every year from raw-dairy products despite legal restrictions in most states.

Cross-contamination in the kitchen

Cutting boards, knives, and bare hands that contact raw meat then contact ready-to-eat foods (salads, fruit) transfer pathogens directly. Separate boards for raw and cooked foods plus hand washing between tasks prevents this.

Improper hot-holding or cold-holding of food

Bacteria multiply rapidly between 40°F and 140°F (4-60°C) — the 'danger zone'. Foods held for more than 2 hours within this range can develop pathogenic counts. Catered events and buffets are particularly prone.

Age under 5 or over 65non-modifiable

Both age extremes have reduced gastric acid secretion, immature or waning immunity, and lower physiological reserve. Hospitalization rates for foodborne salmonellosis exceed 30% in adults over 65 compared to under 5% in young adults.

Pregnancynon-modifiable

Pregnant women are 10 times more likely to develop listeriosis than non-pregnant adults, and listeriosis causes stillbirth in 20% of cases. Cell-mediated immunity is reduced and fetal-placental tropism enables invasive infection.

Immunocompromise (HIV, transplant, chemotherapy, biologics)modifiable

Listeriosis incidence is 100-1000 times higher in solid organ transplant recipients. Non-typhoidal Salmonella bacteremia, severe Cryptosporidium, and prolonged norovirus are all more common in immunosuppressed hosts.

Use of proton pump inhibitors or H2 blockersmodifiable

Reduced gastric acid lowers the infectious dose required for many foodborne pathogens. PPI users have a 2-3 fold higher risk of invasive Salmonella and Campylobacter.

Travel to areas with poor food and water safetymodifiable

Traveler's diarrhea affects 30-70% of visitors to high-risk destinations. Enterotoxigenic E. coli, Campylobacter, Salmonella, Shigella, and norovirus are the most common pathogens; risk persists for the duration of travel.

Consumption of high-risk foods (raw oysters, raw milk, undercooked meat, raw sprouts)

• •Oral rehydration solution as the primary fluid during acute diarrhea
• •Bland, complex carbohydrates: rice, plain noodles, oatmeal, toast — easy to digest, support recovery
• •Bananas — replace potassium lost in diarrhea
• •Plain yogurt with live cultures — modest probiotic benefit
• •Lean cooked proteins (chicken, fish, tofu) as appetite returns
• •Resume normal balanced diet within 24-48 hours; early refeeding shortens illness in children

• •Caffeine, alcohol, and very sugary drinks — worsen dehydration through osmotic diarrhea
• •High-fat or fried foods until symptoms have settled — delays gastric emptying
• •Raw or undercooked meat, poultry, seafood, eggs
• •Unpasteurized milk, cheese, and juices
• •Raw sprouts and unwashed produce
• •Antimotility drugs (loperamide) in dysentery, fever above 38.5°C, or suspected STEC