Diarrhea Flashcards
What are the drugs that commonly cause diarrhea?
Acarbose/miglitol Abx Anti-neoplastics Colchicine Dig Laxatives Synthroid (over replacement) Metocopramide NSAIDs Prostaglandins (misoprostol) Orlistat Sorbitol
What is a watery stool?
Does not have blood or mucus in it
Profuse fluid and electrolyte loss
Fever mild or absent
None or few fecal polymorphonucleocytes (PMNs) in stool
What causes watery stools?
Vibrio cholera
Non-hemorrhagic E Coli
Rotovirus
Norovirus
What is dysentrey?
Mucus and/or blood in the stool Many polymorphonucleocytes (PMNs) in stool
What causes dysentery?
Shigella Salmonella Campylobacter Yersinia Hemorrhagic E Coli Clostridium difficile
What are the different names for hemorrhagic E Coli?
EHEC
STEC
O157
Do not treat w/abx, makes it worse
What is acute diarrhea?
< 3 days duration
What is persistent diarrhea?
4 days to 4 weeks?
What is chronic diarrhea?
> 4 weeks (rarely infectious, most commonly parasitic)
What are the common populations for shigella?
Common in crowded conditions (ie daycare)
What are the common populations for Cryptosporidium parvum?
Swimming pools
Immunocompromised patients including household contacts, sexual partners, healthcare workers, and daycare workers
What are the common causes for cryptosporidium parvum, EHEC?
Pools
What are the common causes for campylobacter?
Exposure to birds, cats, and household chickens
What are the common causes for cholera?
Undercooked seafood
What are the common causes for campylobacter, EHEC)
Red meat
What are the common causes for EHEC ETEC?
Fruits and vegetables
What is the non pharmacologic management of non-infectious diarrhea?
Rehydration
Maintenance of water and electrolytes
As bowel movements decrease, a bland diet is begun
What are anti-diarrheal agents?
Opioid agents Tincture of opium Kaolin & Pectin Bile salt-binding resins Somatostatin and Octreotide Fiber supplements Probiotics Clonidine Verapamil Teduglutide (Gattex)
What is the MOA of opioid agonists in antidiarrheal agents?
Decrease motility of intestinal smooth muscle
What are the types of opioid agonists and clinical pearls?
Loperamide - does not cross the BBB, so no analgesic properties or risk for addiction
Diphenoxylate/Atropine - CV controled substance, no analgesic properties but at high doses CNS effects and opioid dependence can occur. Atropine is included in the product to discourage OD
What are tinctures of opiums?
Colloidal bismuth compounds - bismuth subsalicylate
What is the MOA of bismuth subsalicylate?
Reduces stool frequency and liquidity in acute infectious diarrhea, due to salicylate inhibition of intestinal prostaglandin and chloride secretion. Bismuth has direct antimicrobial effects and binds enterotoxins (useful in traveler’s diarrhea)
What are ADRs of bismuth subsalicylates?
Makes the tongue and stool black (harmless), avoid in renal insufficiency, caution in patients taking warfarin
What is the MOA of Kaolin and Pectin?
Kaolin - Hydrated magnesium aluminum silicate (clay)
Pectin - An indigestible carbohydrate derived from apples
Both - Act as absorbents of bacteria, toxins, and fluid decreasing stool liquidity and number
What drugs should not be given within 2 hours of other medications (which they may bind)?
Kaolin and pectin
Bil salt-binding resins
What are the bile salt-binding resins?
Cholestyramine/colestipol
What is the MOA of bile salt-binding resins?
Bind to bile salts to decrease colonic secretory diarrhea caused by excess fecal bile acids
What are the uses of bile salt-binding resins?
Fecal incontinence, liver dysfunction induced pruritus
What are the ADR of bile salt-binding resins?
Bloating
Flatulence
Constipation
Fecal impaction
What is the MOA of somatostatin and octreotide?
Inhibits gastrin, cholecystokinin, glucagon, growth hormone, insulin, secretin, vasoactive intestinal peptide, and 5-HT
What is the clinical pearl for somatostatin and octreotide?
Useful for secretory tumors that cause diarrhea (example pancreatic tumors)
When are fiber supplements most beneficial?
Hep C patients
What are types of fiber supplements?
Psyllium
Polycarbophil
Methylcellulose
What is the MOA for Fiber Supplements?
Alters texture of stool by gel formation and increased viscosity, improves water retention by stool
What are the ADRs for Fiber supplements?
Bloating
Abdominal fullness
Discomfort
What are the clinical pearls for fiber supplements?
Avoid in patients with a suspected bowel stricture
Useful for diarrhea with enteral nutrition, protease inhibitor induced diarrhea, chronic diarrhea of unknown etiology
What is the MOA of probiotics?
Live microorganisms that replace or re-establish a healthy microbiome
What are the ADRs of probiotics?
Generally considered safe
Caution is warranted in patients who are immunocompromised or in an ICU setting
What is clonidine’s MOA?
Stimulates alpha-2-adrenergic receptors on enterocytes increasing fluid and electrolyte absorption and inhibiting secretion
What are the uses of clonidine in diarrhea?
Diarrhea associated with: Narcotic withdrawal Diabetic diarrhea Chom Graft vs host disease diasrrhea Secretory diarrhea of unknown etiology
What are ADRs of clonidine?
Hypotension
What is the MOA of verapamil?
Blocks calckum channels to prevent calcium from stimulating electrolyte secretion
What is verapamil rarely used?
Hypotension
What is the MOA of teduglutide?
GLP-2 analog which prevents intestinal losses by increasing intestinal and portal blood flow and inhibiting gastric acid secretion
What is the use if teduglutide?
Approved for patients who have short bowel syndrome who are dependent on parenteral nutrition
Which bacteria are seeing FQ resistance world wide?
Campylobacter and Salmonella
What are the most common pathogens associated with traveler’s diarrhea?
ETEC
Shigella
Campylobacter
Salmonella
What are the most common locations to get traveler’s diarrhea?
Latin America
Southern Europe
Africa
Asia
How to prevent traveler’s diarrhea?
Avoid high risk foods/beverages
What can be used for prophylaxis of traveler’s diarrhea?
Bismuth sunsalicylate
What is the treatment for traveler’s diarrhea?
Typically self-limiting (3-5 days) Hydration Antimotility agents (loperamide or diphenozylate) Abx Bismuth subsalicylate is an option
What is Clostridium difficile infection (CDI)?
G+ spore-forming bacteria
Produces toxins A and B that cause illness
How is CDI transmitted?
Fecal-oral route
In healthcare: environmental surface contamination and hand carriage
What are CDI risk factors?
Exposure to abx
Exposure to organism
Age > 65
Others: GI tract surgery, PPIs, IBD
What are high risk abx for CDI?
Clindamycin 2nd and 3rd generation cephalosporins FQs Carbapenems Beta lactams
What are s/sx of CDI?
Foul smelling, watery stools
Abdominal pain
Low-grade fever
Malaise and anorexia
What are IDSA/SHEA guidelines for mild/moderate CDI?
WBC < 15,000 and SCR < 1.5x pre-CDI level
What are IDSA/SHEA guidelines for severe CDI?
WBC >/= 15,000 or SCR >/= 1.5 x pre-CDI level
What are IDSA/SHEA guidelines for severe/complicated CDI?
Severe plus hypotension/shock, ileus, megacolon
What are ACG guidelines for mild/moderate CDI?
Albumin >/= 3 or WBX = 15,000 and NO ab tenderness
What are ACG guidelines for severe CDI?
Ablumin < 3 PLUS WBX > 15,000 or ab tenderness
What are ACG guidelines for severe/complicated CDI?
Attrutable to cDI: ICU admission, hypotension, fever > 38.5C, ileus/ab distention, mental status changes, WBC > 35,000 or < 2,000, lactate > 2.2
What is the diagnosis for CDI?
Real-time PCR for toxin B (repeat test after engative result if high suspicion)
Endoscopy (not common)
Ribotyping
Who should be tested for CDI?
Only stool from patients with diarrhea
All patients with IBD hospitalized with a disease flare or who suddenly develop diarrhea in the ambulatory setting
Pregnant females who develop diarrheal illness
What are CDI infection controls and preventions?
Abx stewardship program is recommended
Insufficient evidence that probiotics prevent CDI
Private room or in a room with another patient with documented CDI
Contact precautions and hand hygeine
Disinfection of surfaces with chlorine agents
What are ACG guideliens for treatment of mild-moderate CDI?
Flagyl 500 mg Po TID x 10
What are the IDSA/SHEA guidelines for treatment of mild-moderate ICD?
Flagyl 500 mg Po TID x 10-14 days
What are ACG guidelines for treatment of severe ICD?
Vanc 125 mg PO QID x 10 days
What are the IDSA/SHEA guidelines for treatment of severe ICD?
Van 125mg po QID x 10-14 days
What are ACG guidelines for treatment of severe/complicated CDI?
Vanc 500mg PO QID +
Flagyl 500mg IV q8h +
Vanc 500 mg per rectum in 500ml QID
What are the IDSA/SHEA guidelines for treatment of severe/complicated CDI?
Vanc 500mg PO QID +
Flagyl 500mg IV q8h
(Vanc 500 mg per rectum in 500ml QID if complete ileus)
What are the ACG guidelines for treatment of recurrent CDI events?
Initial - repeat course
2nd episode - Vanc taper
3rd episode - fecal transplant
What are the IDSA/SHEA guidelines for treatment of recurrent CDI events?
Initial - repeat course
Mutlitple - vanc taper
What is considered a recurrent CDI event?
Repeated episode within 8 weeks
What is the MOA of flagyl?
Inhibition of bacterial protein synthesis
What are common ADRs of flagyl?
Metallic taste Disulfuram reaction (avoid EtOH) Nausea (take with food) Vomiting Tingling in hands/feet
What is the MOA of Vanc?
Inhibits bacterial cell wall synthesis
What is fidaxomicin’s MOA?
Inhibits RNA polymerase to cause cell death
What type of agent should be avoided in CDI?
Anti-peristaltic agents
If used, must be accompanied by abx
