Susceptibility to Infection

Many infections encountered by travellers are associated with increased morbidity and mortality in immunocom-promised persons. These individuals are more likely to have adverse reactions to drugs used to treat infection (Health Canada, 1994).

Malaria. Malaria is a common and serious infectious disease, transmitted by mosquito bites from dusk to dawn. Personal protective measures are very effective in reducing the risk of acquiring malaria. All travellers to endemic areas should be counselled about the use of insect repellent containing DEET on exposed skin, the use of bed nets and to wear clothing that reduces the amount of exposed skin. An insecticide such as permeth-rin or deltamethrin on clothes and bed nets can reduce the risk further.

In many endemic areas, a medication to reduce the risk significantly, but never completely, should be taken. Some of these medications are metabolised at the cytochrome P450. Mefloquine is a good example. Drug interaction should thus be a concern. Other drugs may contain a medication the HIV-infected person is already taking, at a different dose. For example, Malarone contains atovaquone. Other medications could be used with acceptable efficacy for individuals with an already complicated therapy or those who have experienced severe side-effects with previous changes in regimens. Azithromycin, rarely used in practice because of limited efficacy, and primarily cost, is an example. Doxycycline, increasingly used for chloroquine-resistant areas, can increase the risk of photosensitivity or of a recurrence of candidiasis.

Malaria can kill any healthy individual in just 3 days. Because HIV-infected persons are more likely to experience fever as a symptom of opportunistic infection, malaria could go unrecognised and lead to death or severe complications. Travellers and health care providers alike must consider the diagnosis of malaria in any febrile illness that occurs during or after travel to a malaria-endemic area (Health Canada, 1997).

Diarrhoea. Prophylactic antimicrobial agents are not generally recommended for travellers; however, for im-munocompromised travellers, antimicrobial prophylaxis may be considered, depending on the level of im-munosuppression and the region and duration of travel. The use of fluoroquinolones such as ciprofloxacin (500 mg per day), can be considered when prophylaxis is deemed necessary. As an alternative (e.g. for children, pregnant women and persons already taking co-trimoxazole for Pneumocystis carinii pneumonia prophy laxis), co-trimoxazole might offer some protection against travellers' diarrhoea. The risk of toxicity should be considered before treatment with co-trimoxazole is initiated solely because of travel.

Antimicrobial agents such as fluoroquinolones should be given to all patients before their departure, to be taken empirically (e.g. 1 g stat. followed, if diarrhoea persists, by 500 mg of ciprofloxacin twice a day for 3 days) should travellers' diarrhoea develop. Fluoroquinolones should be avoided for children aged less than 18 years and pregnant women, and alternative antibiotics should be considered. Travellers should consult a physician if the diarrhoea is severe and does not respond to empirical therapy, if their stools contain blood, if fever is accompanied by shaking chills, or if dehydration develops. Anti-peristaltic agents (e.g. diphenoxylate and loperamide) can be used to treat mild diarrhoea. They can also supplement the antibiotic treatment if needed (a plane to catch for example). These agents should not be administered to patients who have a high fever or who have blood in the stool.

Some experts recommend that HIV-infected persons who have Salmonella gastroenteritis should be given antimicrobial therapy to prevent extraintestinal spread of the pathogen. However, no controlled study has demonstrated a beneficial effect of such treatment, and some studies ofimmunocompetent persons have suggested that antimicrobial therapy can lengthen the shedding period. The fluoroquinolones, primarily ciprofloxacin (750 mg twice a day for 14 days), can be used when antimicrobial therapy is chosen (USPHS/IDSA, 1999). Fluoro-quinolones should not be used during pregnancy.

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