Outbreak Snapshot — U.S. 2026 (Multistate)
45
States*
6,707
Lab-confirmed*
>11,500
Under review*
423
Hospitalized* (6%)
- One linked multistate outbreak across Illinois, Indiana, Kansas, Kentucky, Michigan, Ohio, Oklahoma, Pennsylvania & West Virginia (9 states): 1,947 exposure-linked cases, at least 98 hospitalized in this outbreak, sourced to shredded iceberg lettuce (grown in central Mexico) served at some Taco Bell locations. Not all locations in those states received the implicated lettuce; Taco Bell has removed it nationwide.
- Supplier: CDC and FDA name Taylor Farms de Mexico on epidemiologic and traceback data. Taylor Farms de Mexico recalled all iceberg lettuce grown in central Mexico on 17 Jul 2026; the recall is complete and no Taylor Farms–branded retail products were involved. No product test has been positive — FDA reported one positive lettuce sample on 18 Jul and retracted it the next day as a false positive, and states there are no confirmed positive product results for Cyclospora. Cyclospora is difficult to detect by conventional product testing, so this does not weaken the epidemiologic link and the recall stands. Store-bought shredded iceberg and lettuce served elsewhere are not implicated.
- Broader national activity (the >11,500 under review) is a separate, still-under-investigation pool — CDC notes some clusters may be unrelated to this outbreak. No deaths reported nationally as of 28 Jul 2026.
- Seasonal (May–Aug) & nationally notifiable; reportable — notify your local/state health department for suspect & confirmed cases.
*CDC lab-confirmed domestically-acquired cases as of 28 Jul 2026, reported by 45 states (up from 4,173 across 41 states the previous week; >11,500 more under review). Hospitalized 423 (6%) is NATIONAL (of 6,707 lab-confirmed); the at-least-98 hospitalized in the bullet above is the Taco Bell 9-state outbreak subset (1,947 linked). State confirmed-plus-probable tallies run well ahead of CDC — Michigan alone reported 10,077 cases on 29 Jul. Nationally 249 cases were reported in the same period of 2025. Median age 44 (range 1–98), 56% female, median illness onset 2 Jul 2026. Numbers are a moving target — approximate, time-stamped & rising; verify against the CDC tracker & your state health department before citing or using clinically.
Pathogen at a Glance
Coccidian protozoan parasite
Route: fecal–oral, food/water
Not believed to spread directly person-to-person
Incubation ~7 d (2–14+)
Sheds oocysts in stool
Season spring–summer
Freshly passed oocysts are not immediately infectious — they need days–weeks to sporulate, so cyclosporiasis is not believed to spread directly person-to-person and produce/water are the usual vehicles.
Treatment & Dosing — Adults & Pediatrics (TMP–SMX is the drug of choice)
| Population | Regimen | Duration | Key notes |
|---|---|---|---|
| Immunocompetent adultCHOICE | TMP–SMX 160/800 mg (1 DS tab) PO BID | 7–10 days | Highly effective. Take with a full glass of water; improvement usually within 1–3 days. |
| Pediatric ≥2 mo–18 yr | TMP 8–10 mg/kg/day + SMX 40–50 mg/kg/day PO ÷ BID (≈ TMP 5 mg/kg/dose) | 7–10 days | Cap ~1 DS tab/dose. Avoid TMP–SMX in infants <2 mo. |
| Immunocompromised / HIV | 1 DS tab PO BID–QID; intensive alt: 1 DS tab PO QID | up to 3–4 wk | Longer/higher dosing often needed; ID consultation recommended; higher relapse risk. |
| HIV secondary prophylaxis | TMP–SMX 1 DS tab PO 3×/week (example) | ongoing | Example regimen — adjust per HIV specialist. Aims to prevent symptomatic relapse until immune reconstitution. |
| Sulfa allergy — alt | Ciprofloxacin 500 mg PO BID | 7 days | Less effective than TMP–SMX; limited comparative data. CDC: no highly effective alternative; consider TMP–SMX desensitization. |
| Sulfa allergy — alt | Nitazoxanide 500 mg PO BID | ~3 days | Limited / anecdotal data for Cyclospora; reserve when cipro unsuitable. |
| All — supportive | Oral rehydration solution; correct electrolytes | as needed | Essential supportive therapy. Avoid routine antimotility agents if febrile or bloody diarrhea. |
Renal: reduce TMP–SMX ~50% when CrCl 15–30 mL/min; generally avoid <15. Pregnancy: folate antagonist (avoid 1st trimester); risks neonatal kernicterus near term.
Clinician Treatment Algorithm
1
Suspect: acute/prolonged watery diarrhea during the 2026 multistate outbreak — especially >3 days or relapsing/remitting; heightened suspicion in states reporting increases.
2
Test (order specifically): often missed by routine stool O&P (unless specifically requested) and absent from some multiplex GI PCR panels. Request Cyclospora-specific molecular assay or ova detection (UV autofluorescence / modified acid-fast). In an active outbreak, consider empiric treatment for a classic presentation per local health-dept guidance.
3
Confirmed / high suspicion → treat with TMP–SMX + rehydration. Stratify by host:
Immunocompetent1 DS tab BID ×7–10 d (peds: wt-based).
ImmunocompromisedHigher/longer; ID consult; 2° prophylaxis.
Sulfa allergy / pregnancyNo equal alt; avoid 1st trimester & near term.
4
Reassess at 3–5 d: if no improvement, recheck adherence, dose/duration, hydration & the diagnosis (co-infection). Extend/intensify in immunocompromised hosts.
Pharmacist Monitoring — TMP–SMX
Labs
- Baseline SCr/eGFR, K+, CBC; recheck with prolonged/high-dose or high-risk hosts.
- Pseudo-rise in creatinine: TMP inhibits tubular Cr secretion → SCr ↑10–15% without true GFR loss.
Adverse effects
- Hyperkalemia (TMP blocks ENaC, amiloride-like), hyponatremia.
- Rash → watch SJS/TEN; photosensitivity; marrow suppression; hepatotoxicity; crystalluria (hydrate).
High-yield interactions
- Warfarin (↑INR — pre-empt), sulfonylureas/repaglinide (hypoglycemia).
- ACEi/ARB/K-sparing diuretics/spironolactone (additive hyperkalemia, esp. elderly); methotrexate, phenytoin, digoxin.
Response & counseling
- Improvement usually 1–3 d; reassess dx if none by day 3–5. Complete the full course (early stop → relapse); hydrate.
Patient Information — Plain Language
Cyclosporiasis is a gut infection from a tiny parasite you can't see, usually caught from contaminated fresh produce or water. It is not believed to spread directly from person to person.
Common symptoms (start ~1 week after exposure):
Watery/"explosive" diarrheaLoss of appetiteWeight lossCramps & bloatingNauseaFatigueLow fever
Symptoms can come and go and relapse; untreated illness may last days to a month+. Antibiotics shorten it considerably.
See a provider / seek testing if you have:
- Watery diarrhea lasting more than a day or two, or that keeps returning
- Dehydration (dizziness, dark/low urine, dry mouth, can't keep fluids down), blood in stool, or fever
- Higher risk: young children, older adults, pregnancy, weakened immune system
Stay hydrated with water & oral rehydration solution, and finish the full antibiotic course to prevent relapse.
Diagnostic Pearls
- Order it on purpose: frequently missed on routine stool O&P unless the lab is asked to look for it specifically.
- Check your PCR panel: some multiplex GI panels omit C. cayetanensis — confirm coverage or send specific testing.
- Oocysts ~8–10 µm; autofluoresce blue-green under UV; variable modified acid-fast staining.
- Think Cyclospora in prolonged/relapsing watery diarrhea in spring/summer or outbreak settings — not cleared by routine "food-poisoning" antibiotics.
Public health: cyclosporiasis is a reportable / nationally notifiable condition. Report suspect & confirmed cases to your local health department and support exposure interviews to help identify the source.
Prevention — Patients & Food Handlers
- Buy whole heads of lettuce over pre-washed bagged mixes; discard outer 2–3 leaves & rinse under running water.
- Wash cilantro, basil & green onions leaf-by-leaf under running water; trim/peel outer layers.
- Cooking kills the parasite (≥158°F / 70°C) — the safest option; washing reduces but doesn't guarantee oocyst removal.
- Foods historically linked: raspberries, basil, cilantro, snow/snap peas, mesclun & bagged salad mixes.
Official Resources & Case Trackers
CDCNational Surveillance / Tracker
cdc.gov/cyclosporiasis/php/surveillance/index.html
CDCAbout (patients)
cdc.gov/cyclosporiasis/index.html
CDCClinical Care (HCP)
cdc.gov/cyclosporiasis/hcp/clinical-care/index.html
CDCOutbreak Investigation (source & traceback)
cdc.gov/cyclosporiasis/outbreaks/07-26/investigation.html
MICHIGANMDHHS Outbreak Page
michigan.gov/mdhhs/keep-mi-healthy/infectious-diseases/cyclosporiasis-outbreak
OHIOODH Cyclosporiasis
odh.ohio.gov › infectious-disease-control-manual › cyclosporiasis
ILLINOISIDPH Cyclospora / 2026 Advisory
dph.illinois.gov › diseases-and-conditions › cyclospora
45 states reporting — for states not listed here, use the CDC national tracker above and contact your state/local health department.