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KEY POINTS
While the incidence of the critical illness among travelers is small, the importance of its evaluation, diagnosis, treatment, and public health response can be profound. This is acutely highlighted with the SARS-CoV-2 pandemic of 2019 to 2022.1,2
Regardless of etiology, the early approach to the critically ill traveler should include a detailed travel history, an appropriate range of diagnostic tests, attention to infection, prevention and control practices appropriate for the syndrome and clinical suspicion, and involvement of public health authorities as appropriate.3–5
Antimicrobial resistance, particularly with carbapenem-resistant gram negative pathogens, is increasing in returning travelers and this directly impacts appropriate initial antimicrobial therapy and subsequent patient outcomes.6,7
Severe Plasmodium falciparum infections should be treated with parenteral therapy recommended for (e.g., intravenous artesunate), and may require coordination with local medication supply or public health authorities in jurisdictions where therapies are in limited supply.8,9
Influenza, coronaviruses, and viral hemorrhagic fevers may all present with a febrile illness along with an acute hypoxemic respiratory failure. Early attention to infection prevention and control, supportive care, syndrome-appropriate therapies—e.g., lung protective ventilation strategies for acute respiratory distress syndrome; steroids and antivirals for COVID-19; antivirals and monoclonal antibodies for a variety of viral illnesses when indicated—are the mainstay of therapy in the critically ill.4,10,11
Rickettsial diseases will include a fever, myalgias, headache, and often include a rash or eschar. In many cases, such as Rocky Mountain spotted fever, Rickettsial disease is difficult to distinguish from other infections until the rash appears. Early therapy with doxycycline is essential in improving outcomes.12,13
Ulcers and painful lymph node syndromes of plague (Yersinia pestis), tularemia, and anthrax may present as a rapidly progressing pneumonia and require antimicrobial therapy for both treatment and prophylaxis.14,15
The coronaviruses SARS-CoV-2, MERS-CoV, and previously SARS-CoV-1 have emerged as important potential sources of acute respiratory failure in a critically ill traveler. The worldwide pandemic causes by SARS-CoV-2 remains the largest event associated with the critically ill and travel and has influenced the management of critical illness worldwide.16,17
Attention to appropriate infection, prevention and control practices, and involvement of public health officials, as appropriate, are important components of the management of infectious causes in the critically ill traveler.4,5
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As international travel has become more accessible over the last 50 years, we have seen a shift in medical epidemiology of travel-associated illness. Until 2018, over 1 billion people worldwide visited a separate country from their current residence will travel outside of their country yearly.1,2,18–20 This includes first- and second-generation immigrants in the developed world who return to their countries of origin while visiting friends and relatives. They can make up almost half of all travelers from the United States.21 This complex web of travel contributed to the rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in 2020 to all corners of ...