Traveler's diarrhea at sea:: Three outbreaks of waterborne enterotoxigenic Escherichia coli on cruise ships

Enterotoxigenic Escherichia coli (ETEC) has become the leading bacterial cause of gastroenteritis outbreaks on cruise ships. Investigation of recent outbreaks of ETEC gastroenteritis on 3 cruise ships indicated that all were associated with consuming beverages with ice cubes on board the ship (relative risk [RR], 1.4, 95% confidence interval [CI], 1.0-1.9, P = .02; RR, 1.9, 95% CI, 1.3-2.9, P < .001; and RR, 1.3, 95% CI, 1.0-1.6, P < .01), and 2 were associated with drinking unbottled water (RR, 2.7, 95% CI, 1.8-4.1, P < .001; RR, 1.7, 95% CI, 1.3-2.3, P < .001). Multiple ETEC serotypes were detected in patients' stool specimens in each of the 3 outbreaks, and 12 (38%) of 32 isolates were resistant to greater than or equal to 3 antimicrobial agents. ETEC appears to be emerging as a waterborne pathogen on cruise ships. Water bunkered in overseas ports was the likely source of ETEC infection in these outbreaks. To ensure passenger safety, cruise ships that take on water in foreign ports must ensure that water treatment and monitoring systems function properly.