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Med School > Diarrhea > Flashcards

Diarrhea Flashcards

1
Q

Harms of early childhood diarrhea

A
  • growth stunting
  • brain development stunting (most before age 2)
  • tied to lower IQ if high burden

*highest burden in the developing world

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2
Q

Definition of diarrhea
Acute watery vs bloody vs persistent

A
  • passage of 3 or more loose stools in 24 hours
    OR >200mL of stool/day

acute watery - hours to days
bloody - inflammatory
persistent - 2+ weeks
chronic - 4+ weeks

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3
Q

Why are children at higher risk of diarrhea?

A
  • higher metabolic rate
  • higher body surface area to weight ratio
  • higher respiratory losses
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4
Q

Signs and symptoms of:
- minimal/ no dehydration
- mild/moderate dehydration
- severe dehydration

A
  • minimal - normal to decreased urine output
  • under 3% weight loss
  • moderate - restless, fatigued, thirsty, increased HR, decreased quality of pulses, slightly sunken eyes, less tears, dry mouth, cool extremities, delayed skin recoil and cap refill, decreased urine output
  • 3-9% weight loss
  • severe - lethargic, unconscious, tachycardia and Brady if severe, no tears, cyanotic/ mottled, impalpable pulses
  • over 9% weight loss
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5
Q

Treatment for:
- mild dehydration
- moderate dehydration
- severe dehydration

A

Mild - often no rehydration therapy needed

Moderate - ORS 50-100mL/kg over 3-4 hours

Severe - IV resuscitation with 20mL/kg saline or Ringer’s lactate for 1h, then 100mL/kg ORS over 5 hours in 1/2 normal saline IV

*if under 10kg weight loss, 60-120mL ORS per stool/vomit
* if over 10kg weight loss, 120-140mL ORS per stool/vomit
*for all 3, continue breast feeding and normal diet

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6
Q

ORS
- how do they work?
- pros?

A
  • oral rehydration salts
  • based on Na and glucose transport coupling via SGLT1 from lumen into epithelial cells (glucose accelerates absorption of solute and water
  • ultimately results in more water absorption into blood
  • cheap, no need for IV, can be given at home, no risk of salt imbalances
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7
Q

Other options for treating dehydration besides ORS

A
  • early refeeding
  • anti-emetics (ondansentron a 5-HT3 antagonist, metoclopramide, domperidone which are dopamine antagonists)
  • ABX if dysentery
  • zinc in the developing world
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8
Q

Lab tests for dehydration

A
  • likely necessary in most mild/moderate cases
  • lytes/BUN/Cr if severe or HUS concern
  • stool microbiology if severe/systemic/bloody/chronic/ young/immunocompromised/travel/outbreak
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9
Q

Common organisms causing diarrhea

A
  • rotavirus
  • shigella
  • ST-ETEC
  • cryptosporidium
  • typical E.coli
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10
Q

Early vs late causes of death in diarrhea. Which is more common?

A

Early - dehydration, lyte imbalances, sepsis

Late - structural changes (blunted villi, deep crypts, inflammation can lead to malnutrition), gut dysbiosis, immune dysfunction, recurrent diarrhea

  • late deaths are 2/3rds of all deaths
  • odds of dying in follow-up much higher if moderate/severe diarrhea
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11
Q

Water sanitation vaccines

A
  • i.e. rotavirus vaccine
  • have higher efficacy in higher GDP countries
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12
Q

Thing that lower vaccine viral titre or impair the immune response

A
  • breast feeding, stomach acid, maternal Ab, OPV lower titer
  • malnutrition (vit A, zinc), interfering microbes, other infxns (HIV, malaria, TB) impair immunity
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13
Q

ABX treatment of Shigella/ trachoma in LMICs

A
  • single dose azithromycin
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14
Q

Where are the majority of gut organisms? What species predominate?

A

large bowel (mostly anaerobes, E.coli)

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15
Q

Role of gut microbiome

A
  • could be linked to immunity, allergy, asthma, obesity, cancer, IBS/D, artherosclerosis, and autism
  • SCFAs affect BBB –> stress, pain, cognition
  • epithelial homeostasis, pathogen protection, nutrient absorption/ fermentation (make B12, folate, vit K, thiamine, etc.), make SCFAs, metabolize bile acids
  • 95% of the human microbiome is in the gut!
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16
Q

Organisms found in:
- water
- oysters/cruisehsips
- children
- food/people/animals
- sheep/cows/produce
- food/people
- food/people/reptiles/ raw eggs
- daycare

A

water - giardia, cryptosporidium, cholera, entamoeba histolytica
oysters/ cruisehips - norovirus
children - rotavirus (most likely to cause hospitalization)
people/food/animals - E. coli ETEC
sheep/cows/produce - E.coli STEC
food/people - shigella
food/people/reptiles/raw eggs - salmonella
daycare - EHEC, shigella, noro/rotavirus

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17
Q

Secretory/ Disordered Electrolyte Transport Diarrhea
- common organisms
- sx

A
  • increased secretion of anions (Cl, HCO3) and/or inhibition of Na absorption
  • watery, continuous despite increased intake/ fasting
  • large stools with a normal proctoscopy
  • mid abdomen pain
  • often SI (cholera, E.coli, rota/norovirus, giardia)
  • cholera is the prototype: interferes with Na/K/Cl transport in enterocytes, more Cl secreted into the lumen (treat with doxy if outbreak)
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18
Q

Inflammatory Diarrhea
- common organisms
- sx

A
  • exudative and protein losses, damage can be direct or immune
  • osmotic secondary to loss of absorptive surface, secretory secondary to inflammatory mediators
  • fever, bloody stool, WBCs in stool, tenesmus
  • lower abdomen and rectal pain
  • small stools with mucosal/friable ulcers
  • often LI (E.coli, salmonella, shigella, C.diff, E.histolytica, campylobacter)
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19
Q

C. Diff
- type of organism
- causes
- consequences
- toxins
- Dx
- Tx

A
  • gram (+) bacillus
  • ABX associated, ESPECIALLY broad spectrum such as ceftriaxone, ciprofloxacin, clindamycin
  • also common with PPIs (less acid to kill spores), institutionalized elderly
  • can lead to pseudomembranous colitis, bloody diarrhea, IBS, toxic megacolon, intestinal perforation, sepsis, death
  • A (entertoxin) and B (cytotoxin) - fluid accumulation, inflammation, increased permeability

Dx - test stool for A/B toxins using ELISA/PCR (B)/culture
Tx - stop ABX, stool transplant, metronidazole or vancomycin or fidaxomicin, surgery if toxic megacolon

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20
Q

E. coli
- type of organism
- reservoir
- virulence factors
- different types

A
  • gram (-) bacilli, can be part of normal gut flora
  • reservoir in guts of humans and animals
  • most common cause of UTIs
  • fimbriae, adhesins, exotoxins (secreted shiga toxin), endotoxin (LPS that prevent phagocytosis, part of cell)
  • ETEC - toxigenic
  • EPEC - pathogenic
  • EIEC - invasive
  • EAEC - aggregative
  • EHEC - hemorrhagic (aka STEC - shiga-toxin producing 0157:H7)
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21
Q

ETEC
- sx
- causes
- toxins
- Tx

A
  • mild watery diarrhea and nausea, NO vomiting, often self-resolving
  • traveler’s diarrhea
  • ingestion of focally contaminated food and water
  • need a LOT to cause disease
  • heat labile (LT) and heat stable (ST) toxin
  • TX: oral rehydration, traveler’s diarrhea vaccine (Dukoral)
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22
Q

STEC (EHEC)
- sx
- causes
- toxins
- what can it lead to?
- tx

A
  • 0157:H7
  • gut of cows and other ruminants, ingestion of cow fecal matter (need a LITTLE to cause disease)
  • usually bloody diarrhea
    -shigatoxin AB - halts protein synthesis in entero/epithelial cells
  • TX - only supportive, NO ABX
  • can lead to HUS (hamburger disease) - low Hgb (schistocytes and helmet cells), not producing urine
  • prodrome of D/V, abdominal pain, 5-10 days later will get oliguria, anemia, lethargy, HTN, renal failure
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23
Q

Salmonella (non-typhoidal vs. typhoidal)

A

Non-typhoidal
- usually non-invasive and self-resolving (4-5 days)
- zoonotic, foodborne (lizards, eggs, fecal contamination)
- acute diarrhea, fever, abdominal pain
- under 5% get invasive (infants, 65+, comorbid)
- no ABX treatment unless invasive or severe

Typhoidal
- only humans are reservoir, fecal-oral transmission
- gastroenteritis, typhoid fever (invasion of peyer’s patches leading to rash, fever, bacteremia and ileum perforation)
- asymptomatic carriage in the gallbladder
- capsular Ag prevents phagocytosis
- Tx: ABX, prevention with hygiene and vaccine
- Dx: bacteriology or molecular PCR

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24
Q

H. Pylori
- transmission
- virulence factors
- what can it lead to
- sx
- tx

A
  • fecal-oral, oral-oral transmission
  • infects lower stomach antrum, urease to neutralize acid, spiral flagella, mucolytic enzymes, adhesions to epithelial receptors
  • most common cause of gastritis (duodenal and gastric ulcers, increases risk of gastric cancer), most common chronic bacterial infix
  • seroprevalence dependant on age and SES
  • nausea, vomiting, epigastric pain, anorexia, acid reflux

Tx - quadruple therapy for 14 days (2nd option is if penicillin allergy)
- PPI BID
- clarithromycin or bismuth
- amoxicillin or metronidazole
- metronidazole or tetracycline

  • test for eradication 4 weeks off ABX and 2 weeks off PPI
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25
Q

Test for H. pylori - who should be tested?

A
  • urease breath test (urea –> NH4 and labeled CO2)
  • stool Ag test
  • endoscopy if alarm features/ drug resistance (bleed, anemia, weight loss, dysphagia, hx of cancer, early satiety)
  • serology very sensitive but (+) up to 18m
  • test if dyspepsia, hx of ulcers or upper GI bleeds or gastric cancer, immigrants, indigenous
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26
Q

Hepatitis A

A
  • picornavirus, fecal-oral
  • replicates in hepatocytes
  • fatigue, N/V/D, abdominal pain –> jaundice, pruritic, dark urine, pale stools, usually self-limiting and liver failure is uncommon
  • cryoglobinemia, glomerulonephritis, arthritis, leukovasculitis
  • Tx: supportive, vaccine (2 doses 6m apart, recommended for everyone 6m and older) recovery in 2-3 months
  • no chronic illness and immunity is lifelong
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27
Q

Food poisoning definition
staph aureus vs bacillus cereus food poisoning

A
  • acute onset of N/V and pain within 1-6 hours of ingestion, resolves within 24 hours without treatment

staph aureus - multiplies at room temp and produces enterotoxin

bacillus cereus - common in rice, spores survive cooking and germinate, produce enterotoxin at room temp

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28
Q

Clostridium botulinum (botulism)
- type of organism
- causes
- toxin
- consequences (in infants and adults)
- dx
- tx

A
  • gram (+) spore forming rod anaerobe
  • common in soil, vegetation
  • germinates in low oxygen environment and produces neurotoxin that cleaves SNARE proteins (prevents Ash release)
  • can germinate in infant guts and cause floppy Abby syndrome (hypotonia)
  • in adults - double vision, dropping eyelids, dry mouth, dizziness, dysarthria, dysphagia, diaphragm paralysis and death
  • Dx: clinical, toxin detection in stool and serum
  • Tx: anti-toxin IgG and respiratory support
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29
Q

Abdominal Abscess
- what is it and what can it cause
- most common pathogens
- tx

A
  • disruption of the bowel wall allowing normal flora to cause disease int he peritoneum
  • mechanical obstruction, inflammation, surgery, etc.
  • WBC are recruited, can lead to necrotic death
  • most common pathogens are E.coli and bacteroides, but can also be candida/enterococcus if ABX/ hospital
  • Tx: if septic pip-tazo OR ceftraixone + metronidazole (always have anaerobe coverage)
  • surgical drainage
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30
Q

Typical Bowel Flora

A
  • enterobacter (E.coli, proteus, klebsellia, enterbacter)
  • anaerobes (bacteroides, clostridium, fusobacterium)
  • strep/enterococcus, candida, staph aureus
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31
Q

Tx for Amoebic Liver abscess caused by entamoeba hystolitica

A
  • metronidazole 5-10 days, paramomycin or iodoquinol
  • common in MSM and immigrants
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32
Q

Esophagitis
(immunocompromised)

A
  • Candida albicans yeast colonizes
  • infection with loss of mucosal barrier, immune deficiency, ABX use
  • oral thrush is the most common opportunistic HIV infection - dysphagia, odynophagia, N/V, anorexia

Tx - fluconazole 14-21 days

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33
Q

HSV
(immunocompromised)

A
  • reactivation of herpes virus
  • most commonly oral/CNS/esophagitis/hepatitis/genital ulcers

Tx - acyclovir, valacyclovir, prophylaxis if outbreak

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34
Q

CMV
(immunocompromised)

A
  • reactivation of herpes virus
  • most commonly esophagitis/ retinitis/ colitis/ hepatitis/ pneumonia

Tx - ganciclovir, valganciclovir, reduce immune suppression

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35
Q

Mycobacterium Avium Complex (MAC)
(immunocompromised)

A
  • non-TB mycobacterium in soil and water
  • can colonize respiratory or GI tract
  • Dx: fever/ fatigue/ weight loss/ diarrhea/ cough/ lymphadenopathy, imaging, culture, histology of colon/bm/lymph nodes

Tx - rifabutin, ethambutol. clarithromycin, decrease immune suppression

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36
Q

Protozoa
(immunocompromised)

A
  • can cause chronic diarrhea
  • treat with TMP-SMX
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37
Q

Strongyloides Stercoralis

A
  • roundworm
  • enter via feet into lungs then SI
  • Gi hemorrhage, gram (-) bacteremia, meningitis, pneumonitis
38
Q

Examples of inhibitors of:
- B-lactams
- Folate synthesis
- Nucleic Acid synthesis
- DNA gyrase
- 50S subunit
- 30S subunit
- Cell membrane
- Cell wall synthesis

A
  • B-lactams - penicillins, cephalosporins, carbapenems
  • Folate synthesis - sulphonamides, trimethoprim
  • Nucleic Acid synthesis - metronidazole
  • DNA gyrase - quinolones
  • 50S subunit - macrolides, clindamycin, linezolid
  • 30S subunit - tetracyclines
  • Cell membrane - daptomycin
  • Cell wall synthesis - vancomycin
39
Q

ABX that are 90%+ bioavailable

A
  • doxycycline
  • metronidazole
  • TMP-SMX
  • rifampin
  • linezolid
  • fluconazole
  • fluroquinolones
40
Q

Gram (+) Bacilli vs Cocci

A

bacilli - clostridium, listeria, corynebacterium, bacillus

cocci - streptococcus, enterococcus, staphylococcus

41
Q

Tx for:
- Listeria
- Enterococcus
- Strep pneumo
- Strep A/B/C
- Viridans Group Strep
- Staph Aureus (MSSA and MRSA)

A
  • Listeria - Ampicillin
  • Enterococcus - Ampicillin/ Amoxicillin
  • Strep pneumo - Amoxicillin/ Penicillin or Ceftriaxone/ Cefuroxime
  • Strep A/B/C - Penicillin
  • Viridans Group Strep - Penicillin
  • Staph Aureus (MSSA and MRSA) - Cloxacillin or Cephalexin/Cefazolin for MSSA, Vancomycin for MRSA
42
Q

Vancomycin
- MOA
- use
- S/E

A
  • inhibits peptidoglycan (and thus cell wall) synthesis
  • only acts against gram (+)
  • nephrotoxicity, rash, cytopenias, red man syndrome
  • SAFE IN PREGNANCY AND CHILDREN
43
Q

Daptomycin
- MOA
- use
- S/E

A
  • binds bacterial membrane and causes depolarization, K efflux, and cell death
  • only IV and only works against gram (+)
  • commonly used for MRSA and VRE infections if vancomycin cannot be used
  • increased CK levels, muscle weakness, myalgia
44
Q

Linezolid

A
  • binds and prevents translocation (50S), thus preventing protein synthesis
  • only works against gram (+)
  • both IV and oral, great bioavailability
  • commonly used for MRSA and VRE infections
  • serotonin syndrome if on SSRIs, neuropathy, bone marrow suppression
45
Q

Gram (-) cocci vs. coccoid rods vs. rods

A

Cocci - n.meningitidis, n.gonorrheae

Coccoid rods - H. flu, B. pertussis

Rods - pseudomonas, shigella, salmonella, enterbacteraciaea

46
Q

What is the major resistance mechanism in gram (-)? Which organisms have these? What drugs counteract this?

A
  • B-lactamases

SPACE organisms aka ESBL (ampC gene):
- Serratia
- Proteus/ Pseudomonas
- Acinetobacter
- Citrobacter
- Enterobacter

  • pip-TAZO and amox-CLAV
  • carbapenems
47
Q

Concerns for gram (-) organisms

A
  • lower GI and GU infections
  • nosocomial infections (HAP)
  • chronic wound infections with previous BAX use
48
Q

Which ABX do you use for:
- ESBL
- pseudomonas
- N. gonorrhea
- H. flu
- enterbacteraciae

A

ESBL - carbapenems
pseudomonas - carbapenems, pip-tazo
N. gonorrhoea - ceftriaxone/ cefixime and azithro
H. flu - amoxicillin-clav
Enterobacteraciaea - amor-clav, pip-tazo, carbapenems, ceftriaxone

49
Q

TMP-SMX
- uses
- s/e

A
  • MRSA, listeria, pneumocystis jirovecii
  • hyperkalemia, rash (SJS), nephrotoxicity, neutropenia, hemolytic anemia, kernicterus (NO in last 2m of pregnancy and 1st year of life)
50
Q

Examples of anaerobic bacteria

A
  • C. diff and actinomycetes (+)
  • Bacteroides and fusobacterium (-)
51
Q

Metronidazole
- MOA
- uses
- s/e

A
  • disrupts DNA synthesis in anaerobes and protozoa
  • 1st line for non-severe C. diff, giardia, bacteroides, H. pylori, bacterial vaginosis
  • N/D, metallic taste, cannot take with alcohol
  • OK IN PREGNANCY
52
Q

Clindamycin
- MOA
- uses

A
  • binds and blocks peptide exit thus inhibiting protein synthesis (50S)
  • oral anaerobes, MRSA, severe group A strep, necrotizing fasciitis
53
Q

Rule of thumb ABX for:
- above the diaphragm
- below the diaphragm
- everywhere

A
  • Above - clindamycin and metronidazole
  • Below - metronidazole (i.e. acute GI infection, likely gram (-) and anaerobes)
  • Everywhere - pip-tazo, amox-clav, carbapenems
54
Q

Bristol Stool Chart

A

1 - hard lumps
7 - entirely liquid

  • 6 or 7 is considered diarrhea
55
Q

How is water absorbed in the intestines? Where is most of it absorbed?

A
  • salt-driven (glucose dependent Na/K transport)
  • occurs near tip of villi
  • most water is absorbed in the jejunum (6L), in contrast max colonic absorption is 4L which has an active Na/K channel
56
Q

Osmotic/ Malabsorptive Diarrhea

A
  • poorly/ non-absorbed solutes (Mg, PO4, lactose, lactulose, sucrose, sorbitol, mannitol)
  • intestines cannot maintain the osmotic gradient and thus water tension in the lumen is needed to maintain osmolality
  • can be caused by laxatives (PEG), congenital sugar malabsorption, celiacs
  • disappears with fasting/ stopped consumption of the offending agent
57
Q

Altered Intestinal Transit Diarrhea

A
  • more fluid = propulsion = decreased absorption = diarrhea
  • slow transit can lead to SI bacterial overgrowth, leading to fat malabsorption and bile acid secretory diarrhea (DM, autonomic neuropathy, post OP)
58
Q

Causes of chronic diarrhea

A
  • protozoa (giardia, cryptosporidium)
  • C.diff
  • TB (in general, higher risk if immunocompromised)
  • fatty - malabsorption and maldigestion (celiac’s, chronic pancreatitis)
  • inflamm - diverticulitis, IBD, neoplasia, TB, C.diff, CMV, HSV, parasites
  • watery - IBS, Addison’s, neuropathy, hyperTH, hypoPTH, LOTS of stuff
59
Q

Dietary drug causes of diarrhea

A
  • excess coffee, alcohol, antacids, ABX, NSAIDs, SSRIs
60
Q

Bile Acid Malabsorption Diarrhea

A
  • common in IBD
  • primary - impaired FGF19 feedback
  • secondary - Crohn’s, DM, resections, chemo, cholecystectomy
61
Q

Chronic Pancreatitis

A
  • malabsorption when exocrine secretion capacity is under 90%
  • lipase and co-lipase will fall first, leading to fatty osmotic diarrhea
62
Q

Use of fecal calprotectin

A
  • correlates with inflammatory diarrhea if 200+
  • NOT specific for IBD
63
Q

Tests for:
- SIBO
- pancreatic insufficiency
- crohn’s
- watery, new sx 40+, hemochezia, alarm sx, anemia, increased CRP or calprotectin

A
  • SIBO - glucose hydrogen breath test
  • pancreatic insufficiency - fecal elastase, pancreatic CT, secretin/CCK stim tests
  • Crohn’s - MR/CT enterography
  • watery, new sx 40+, hemochezia, alarm sx, anemia, increased CRP or calprotectin - colonoscopy
64
Q

Antidiarrheals

A
  • loperamide (ammonium) - m-opioid agonist
  • opiates, codeine, cholestyramine, bismuth subsalicylate, anticholinergics kaolin, psyllium, cellulose
  • NEVER use if fever/ abdominal distension
65
Q

Celiac’s

A
  • increased immune response to Gliadins
  • HLA-DQ2 haplotype in 90%, HLA-DQ8 in rest
  • EMA IgA and ttG IgA
  • SI biopsy is required for diagnosis
  • can be asx, epilepsy, arthritis, myopathy, dermatitis herpetiformis, malnutrition, osteoporosis, malignancy, T1DM, dementia
  • osmotic fatty diarrhea due to malabsorption
  • less villi, crypt hyperplasia, bile irritation (secretory and inflammatory)
  • Tx - gluten exclusion, steroids and immunosuppressants
66
Q

IBD (Crohn’s vs UC)
-tx?

A

Crohn’s - any part of GI tract, inflammation penetrates leading to ulcers (transmural), skip lesions, stenoses/ fistulas, granulomata
- smoking hurts

UC - only in LI, always affects rectum, continuous, mucosal, never SI or anus
- smoking helps

Tx - prednisone/budesonide –> AZA/MTX –> biologics (JAKis i.e. tofactinib for UC) –> surgery
- anti-TNFs (infliximab)

67
Q

Where are bacteria more abundant in the gut?

A
  • proximally and where higher pH
68
Q

Dominating gut biome species in infants vs adults

A
  • bifidobacteriaciae
  • firmicutes and bacteroidetes
69
Q

Why are plant protein and fiber good for us?

A
  • decrease inflammation by increasing SCFA production
  • maintain healthy pH, associated with bacterial richness
70
Q

Prebiotics

A
  • inulin, FOS/GOS, lactulose (mainly plant foods)
  • stimulate SCFAs, increase satiety/ glycemic control/ Ca absorption/ mucosal barrier, decrease inflammation/ toxins

*not much evidence supporting probiotics

71
Q

Drugs that affect the microbiome

A
  • metformin, NSAIDs, atypical antipsychotics
  • PPIs have biggest effect after ABX (increased risk of C.diff and campylobacter)
72
Q

Consequences of dysbiosis

A
  • alteration of bile acids –> inflammation –> decreased motility –> GI cancer
73
Q

Vomiting Red Flags in Children

A
  • neonates (especially in bilious)
  • projectile
  • hypovolemia/ shock
  • severe abdominal pain, peritonitis
  • lethargy
  • fever (+/- stiff neck/ headache) epsecially if travel history

*UTI very common cause of fever and vomiting in children, always test

74
Q

Intussusception

A
  • bowel telescopes in on itself (commonly ileocecal)
  • young (3m-3y), acute episodes of cramps pain and vomiting, bilious emesis, stiffening and pulling of legs to abdomen, lethargy or low LOC
  • may feel well and fall asleep in-between episodes
  • “red currant jelly” bloody stool
  • life threatening!
  • Dx - U/S, barium/air enema
  • a 1 day old with bilious vomiting is often a surgical cause
75
Q

Hypertrophic pyloric stenosis

A
  • 3w-3m
  • non-bilious vomiting
  • Dx w U/S
76
Q

Corynebacterium Diptheriae
- tx

A
  • common upper respiratory pathogen leading to pharyngitis and pseudomembrane over tonsils - can lead to obstruction and death (bull neck)
  • person-person spread

Tx - penicillin or azithromycin, supportive

77
Q

Case Reproduction Number (R)

A
  • average number of secondary cases attributable to a single case
  • anything more than 1 allows for an epidemic
  • R = contact rate x transmission risk per contact
  • R=1 means disease is endemic
  • R=3 is intitial phase of epidemic (exponential growth)
78
Q

Odds Risk (OR)

A
  • odds disease if exposed/ odds disease if unexposed
                      Disease?
                  \+        - Exposure +    A.       B
            -    C.        D

= (A/B)/ (C/D) or (AD/BC)

79
Q

When to use empiric treatment for diarrhea

A
  • good evidence for traveler’s diarrhea –> loperamide
    - ciprofloxacin or azithro if SE Asia
  • no if bloody unless younger than 3 months, severely ill with a fever, or recent exposure to shigella
  • no in watery diarrhea unless infant or immunocompromised
  • only use for C.diff if leukocytosis/ abdo pain/ AKI
80
Q

What should you never treat?

A

EHEC 0157:H7, other STEC, and salmonella (unless chronic carrier with high risk of transmission

81
Q

Test Cure for ABX treatment

A
  • don’t bother, post-tx colonization is very common
  • goal is to eliminate toxin, not the organism
82
Q

Major determinant of development and education and subsequent obesity and non-communicable diseases in adulthood

Major roots of inequity

Protective Factors

A
  • undernutrition in 1st 1000 days of life
  • poverty, status of women, less education, war
  • breast feeding, maternal education, support programs
83
Q

Micronutrient Supplementation

A
  • iron (anemia, developmental delay, energy, learning)
  • iodine (developmental delay)
  • zinc (pneumonia, diarrhea)
  • vit A (eyesight, measles mortality)
84
Q

Malaria
- carried by? transmission?
- most common type?
- MOA?
- immunity?

A
  • cause of returning traveller fever until proven otherwise
  • carried by female anopheles mosquito
  • bites occur at night, transmission is temperature dependent
  • plasmodium falciparum is most common and most serious
  • parasites multiply in liver cells and RBCs (lyse)
  • can have partial immunity in areas of constant transmission
  • immigrant immunity wanes in 6 months
85
Q

Uncomplicated malaria vs. severe malaria (p. falciparum)

A
  • fever, rigours, headache, myalgia, anorexia
  • +/- jaundice, splenomegaly, pallor if chronic
  • confusion (even intermittent), seizures, coma, renal failure, pulmonary edema, hypoglycaemia, lactic acidosis, coagulation issues, jaundice, shock
  • 10-20% mortality even with treatment
86
Q

How to Dx malaria

A
  • microscopy (thick and thin blood smears) - can determine species and parasitemia (% of RBCs infected)
  • a negative blood smear does NOT rule it out
  • rapid Ag tests - easy, cannot always speciate or determine parasitemia, can have false (-)
87
Q

Malaria Treatment

A
  • if uncomplicated - artemether-lumefantrine oral OR atovaqune-proguanil (artemisinin-based combo therapy - ACT)
  • quinine and doxy/clinda in Canasa
  • chloroquine (if sensitive area) and primaquine (gets hypnozoites dormant in liver)
  • if severe - ACT, artesunate IV and doxy or clindamycin
  • hospital admission

prophylaxis - mefloquine weekly

88
Q

Big 3 Fever Viruses in Travellers
- presentations
- spread
- testing
- tx

A
  • Dengue - diffuse blanching rash and petechiae
  • hemorrhagic fever, shock
  • serology
  • Zika - conjunctivitis
  • GBS, fetal microcephaly if in-utero
  • PCR if under 10 days, serology
  • no sex for 2 months (woman) or 6 months (male)
  • Chikungunya
  • persistent post-infectious arthralgia
  • serology
  • all present with fever, arthralgia, headache, rash, N/V/D
  • aedes mosquito, biting occurs in the day, stagnant water in urban areas
  • Tx - supportive care only
89
Q

Typhoid

A
  • salmonella typhi, fecal oral transmission (contaminated food and water)
  • highest risk in south asia
  • prolonged fever, fatigue, headache, apathy, bradycardia, leukopenia
  • can lead to intestinal perforation, bleeds, sepsis
  • CONSTIPATION IN ADULTS
  • DIARRHEA IN KIDS

Dx- repeated blood cultures
Tx - ceftriaxone or azithromycin
- vaccine, but not 100% effective

90
Q

Rickettsia

A
  • intracellular bacteria, fleas/lice/mites/ticks
  • various kinds of typhus and spotted fevers

Tx - doxycycline

Med School (21 decks)

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