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Gastrointestinal Infections Flashcards

1
Q

Obtain a good medical history, what information is pertinent?

A 
Certain sexual practices
Hospitalizations
LTC facilities
Child care facilities
Foodborne or waterborne
International travel
Antimicrobial agents
Immunocompromised host
Animal exposure
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2
Q

Diarrhea defined:

A

↓in the consistency of bowel movements (i.e. unformed stool); ↑ in frequency of stools (> 3 per day)

NOTE:
Infectious diarrhea
Vomiting and diarrhea are responsible for much of the morbidity & mortality

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3
Q

Acute diarrhea

A

<14 days duration

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4
Q

Chronic diarrhea

A

≥ 14 days duration

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5
Q

Acute infectious diarrhea (I.D.):

A

Globally
-Younger children (< 5 yrs) are at higher risk of death from acute dehydrating diarrhea

In the United States:
-Highest risk of mortality is the elderly (as opposed to children, in the developing world)

Others at risk: travelers, campers, pts in chronic care facilities, military personnel stationed abroad, immunocompromised pts

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6
Q

Watery diarrhea vs. dysentery

A

Diarrhea is a condition that involves the frequent passing of loose or watery stools.

Dysentery is an intestinal inflammation, especially in the colon, that can lead to severe diarrhea with mucus or blood in the feces.

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7
Q

Watery diarrhea:

  1. appearance
  2. volume
  3. number per day
  4. reducing substances
  5. pH
  6. occult blood
  7. fecal PMNs
A
  1. watery
  2. increased: ++/+++
  3. < 10
  4. 0 to +++
  5. 5 - 7.5
  6. negative
  7. absent or few
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8
Q

Dysentary:

  1. appearance
  2. volume
  3. number per day
  4. reducing substances
  5. pH
  6. occult blood
  7. fecal PMNs
A
  1. bloody
  2. increased: +/++
  3. > 10
    1. 0
  5. 6 – 7.5
  6. positive
  7. many
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9
Q

Watery diarrhea:
Complications
1. dehydration
2. others

A
  1. could be severe

2. acidosis; shock; electrolyte imbalances

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10
Q

Dysentary:
Complications
1. dehydration
2. others

A
  1. mild

2. tenesmus; rectal prolapse; seizure

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11
Q

Watery diarrhea: Etiology

A

Vibrio cholerae
Enterotoxigenic E. coli (ETEC)
Rotaviruses
Noroviruses

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12
Q

Dysentary: Etiology

A 
Shigella
Salmonella
Campylobacter spp.
Enterohemorrhagic E. coli (EHEC)
Yersinia spp.
Clostridioides difficile
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13
Q

DYSENTERY
(bloody; inflammatory)

Cause:

Signs and Sx:

A

Cause is mostly bacterial (i.e. EHEC, Shigella, Salmonella, & Campylobacter)
Mucoid stool ± blood
Lower abdominal cramping w/ pain
Fever is more common
Colon is affected
Colonic ulceration occurs in addition to infection of upper epithelial cells
Cells are attacked and destroyed
Antimicrobials can eradicate the pathogen and stop the inflammation
Major systemic complications are possible

Almost always requires antibiotic treatment (IV antibiotics may be needed). EXCEPT for EHEC do NOT use antibiotics in EHEC!!

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14
Q

WATERY DIARRHEA
(enterotoxigenic; noninflammatory)

Cause:

Signs and Sx:

A

Cause is mostly viral (Norovirus & rotavirus > ETEC & Cholera)
Watery stool; no blood or mucous
± Cramping & pain
Fever is uncommon
Small bowel is affected
Infection & targeting of intestinal lumen & upper epithelial cells
No cell death; infection is due to toxins
Antimicrobials don’t eradicate the toxin
Less serious than dysentery; dehydration is major risk

Antimicrobial treatment not needed (oral or IV rehydration may be necessary)

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15
Q

Causative Organisms
Watery diarrhea (enterotoxigenic)
Non-invasive:

A

Rotavirus
Norovirus
Enterotoxigenic E. coli
Cholera (not in the U.S.)

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16
Q

Causative Organisms
Dysentery (bloody diarrhea)
Invasive

A 
Shigella
Salmonella 
Campylobacter
Enterohemorrhagic E. coli
Yersinia enterocolitica
Clostridioides difficile
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17
Q

Watery diarrhea:

Norovirus

A

Account for > 90% of viral gastroenteritis among all age groups
Healthcare systems, cruise ships, college dorms

(previously known as Norwalk-like viruses)

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18
Q

Watery diarrhea:

Rotavirus

A

Is ubiquitous and infects most children < 5 yrs

After infection, 40% of children are protected against subsequent infection

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19
Q 
Watery diarrhea:
Vibrio cholerae (Cholera)
A

Gram-negative bacillus (similar to enterobacteriaceae)
Toxigenic C. cholerae serogroups 01 or 0139
Severe and voluminous diarrhea (watery diarrhea)
Not common in the U.S. due to sanitation of water systems

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20
Q

Watery diarrhea:

Enterotoxigenic E. coli (ETEC)

A

Accounts for ½ of all cases of E. coli diarrhea
Most common cause of traveler’s diarrhea
A common cause of food- and water-associated outbreaks

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21
Q

E. coli causing watery diarrhea

Toxin-producing:

A

Enteroaggregative E. coli (EAEC)

Enterotoxigenic E. coli (ETEC)

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22
Q

E. coli causing watery diarrhea

Non-toxin-producing

A

Enteroinvasive E. coli (EIEC)

Enteropathogenic E. coli (EPEC)

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23
Q

E. coli causing dysentery

Toxin-producing

A

Enterohemorrhagic E. coli (EHEC)

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24
Q

Viral Gastroenteritis

Norovirus:

A 
All age groups
Peak in winter
2-3 days
Fecal-oral, food, water, environment
Nausea, vomiting diarrhea, abdominal cramps, myalgia
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25
Q

Viral Gastroenteritis:

Rotavirus:

A

6 months to 2 years
October to April
3-7 days
Fecal-oral, water, food

Nausea, vomiting, diarrhea, fever, abdominal pain, lactose intolerance

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26
Q

Bacterial Gastroenteritis: E. coli
Enterotoxigenic
E. coli (ETEC)
Watery

  1. Toxin Production?
  2. Incubation period
  3. Duration
  4. Mode of transmission
  5. Common symptoms
A
  1. YES
  2. 1-3 days
  3. 3-4 days
  4. Contaminated food or water with human or animal feces
  5. Watery diarrhea and abdominal cramping
    Responsible for ½ of all E. coli diarrheal illness; common cause of food/water outbreaks
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27
Q

Bacterial Gastroenteritis: E. coli
Entero-hemorrhagic
E. coli (EHEC):
Dysentary

  1. Toxin Production?
  2. Incubation period
  3. Duration
  4. Mode of transmission
  5. Common symptoms
A
  1. YES
  2. 3-4 days
  3. NR
  4. Uncooked beef or unpasteurized milk or juice
  5. Gastroenteritis, enterocolitis, sometimes bloody diarrhea and hemolytic-uremic syndrome
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28
Q

Bacterial Gastroenteritis:
Vibrio cholerae

  1. Incubation period
  2. Duration
  3. Mode of transmission
  4. Common symptoms
A
  1. 2 – 3 days
  2. 1 – 3 days
  3. Contaminated food or water with human feces usually in areas of inadequate treatment of sewage and drinking water
  4. Profuse watery diarrhea, vomiting, and leg cramps; Death can work within hours without treatment
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29
Q

Bacterial Gastroenteritis:
Salmonella nontyphoidal

  1. Incubation period
  2. Duration
  3. Mode of transmission
  4. Common symptoms
A
  1. 12 – 36 hours
  2. 1 – 5 days
  3. Contaminated food, water, or contact with infected animals
  4. Diarrhea (sometimes bloody), fever, and abdominal cramps
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30
Q

Bacterial Gastroenteritis:
Shigella spp.

  1. Incubation period
  2. Duration
  3. Mode of transmission
  4. Common symptoms
A
  1. 1 – 3 days
  2. 1 – 7 days
  3. Fecal-oral contaminated food or water with infected human feces
  4. Watery or bloody diarrhea (8-10 stools/day), severe abdominal pain, fever, and malaise
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31
Q

Enterohemorrhagic E. coli (EHEC):

Include strains that include:

A

Shigatoxigenic Escherichia coli (STEC)
Produces shiga toxin
Causes 50-60% of all EHEC infections
A type of EHEC, E. coli 0157:H7
can cause bloody diarrhea and hemolytic uremic syndrome (anemia and kidney failure)
A minority of the strains cause illness in humans
The strains that DO cause illness in humans are collectively known as Enterohemorrhagic E. coli (EHEC)

Major causes of foodborne illness

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32
Q

(Nontyphoid) Salmonella enterica

A

Gram-negative bacilli

Belongs to the Enterobacteriaceae family

Gastroenteritis is cause by:

  • Serotypes Typhimurium and Enteritidis
  • In the U.S. the largest burden of Salmonella infection is due to nontyphoidal serotypes
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33
Q

Shigella spp.

A

Produces shigellosis

Associated with poor sanitation or personal hygiene, inadequate water supply, malnutrition, and increased population density

S. sonnei and S. flexneri:
-The most common causes of gastroenteritis in the U.S.

S. dysenteriae type 1 and S. boydii
-Commonly acquired during travel

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34
Q 
Watery Diarrhea (Acute Gastroenteritis)
Enterotoxigenic E. coli (ETEC)
A

Produces watery diarrhea due to severe intestinal water secretion

Produces 2 toxins
-Heat-stable toxin (ST); heat-labile toxin (LT)

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35
Q 
Watery Diarrhea (Acute Gastroenteritis)
Rotavirus
A

Produces a viral enterotoxin

Induces changes in fluid balance by destroying the epithelial lining of the intestine, and vascular damage and ischemia in villi.

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36
Q

Watery Diarrhea (Acute Gastroenteritis)

A

Altered movement of ions and water, resulting in increased colonic secretion

Classic enteric pathogens that cause watery diarrhea in the U.S.
-V. cholerae, ETEC, rotavirus, and norovirus

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37
Q 
Watery Diarrhea (Acute Gastroenteritis)
V. cholerae
A

Produces classical secretory diarrhea due to cholera toxin

Toxin consists of 2 subunits, A and B

Toxin acts along the entire intestinal tract

Net effect of the cholera toxin: fluid secretion exceeds absorptive capacity

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38
Q

Inflammatory diarrhea (Dysentery)
Caused by 2 groups of organisms:
1.) Enterotoxin-producing, noninvasive bacteria

A

Adhere to the mucosa, activate cytokines, stimulate the intestinal mucosa to release inflammatory mediators

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39
Q

Inflammatory diarrhea (Dysentery)
Caused by 2 groups of organisms:
2.) Invasive organisms: Campylobacter spp., Salmonella spp., Shigella spp.

A

Invade the intestinal mucosa to induce an acute inflammatory reaction
Involves the activation of local and systemic cytokines and inflammatory mediators

40
Q

Diarrhea

Noninflammatory

A

diarrhea that produces watery diarrhea

41
Q 
Diarrhea
Inflammatory diarrhea (dysentery)
A

Bloody stool and mucous

Fever is often present

42
Q

Norovirus or ETEC

A

Mild, self-limiting disease

43
Q

Cholera

A

Severe, dehydrating diarrhea

44
Q

Diagnosis Stool Culture

A

Gold Standard = Diarrheal stool sample (i.e., a sample that takes the shape of the container)

  • Checks for Salmonella, Shigella, E. coli 0157:H7 (SHEC)
  • Checks for Ova and Parasites

Blood Culture
-Septicemia, enteric fever, systemic manifestations, immunocompromised patients, people with high-risk conditions

Molecular techniques
-More sensitive and less dependent than culture on the quality of specimen

Other
-Stool leukocytes, stool occult blood, stool Giardia antigen

45
Q

Complications

A

Usually arise secondary to dehydration so…
-Treatment focuses on rehydration regardless of the cause

Bacteremia
More common in immunocompromised patients (HIV infection, malignancy, malaria)

46
Q

Complications

A complication of EHEC

A

Hemolytic-uremic syndrome (HUS)

Defined by the following triad:

1) Acute renal failure
2) Thrombocytopenia
3) Hemolytic anemia

47
Q

Complications
Shigella infection
Can lead to complication such as:

A

Seizures, sepsis, toxic megacolon, perforated colon, arthritis, & protein-losing enteropathy

Reiter syndrome

  • < 3% with S. flexneri will develop
  • Characterized by joint pain, irritation of the eyes, painful urination; chronic arthritis may develop
48
Q

Complications

Reactive arthritis

A

Occurs 1-2 weeks after gastroenteritis secondary to S. flexneri, Salmonella spp., C. jejuni, and Y. enterocolitica
Can involve knees, ankles, toes, fingers, wrists etc.
Usually resolves in 1-4 months but may persist in ~10% of patients

49
Q

Complications

Post infectious irritable bowel syndrome (IBS)

A

Symptoms (recurrent abdominal pain or discomfort) can last ~3 months following an episode of gastroenteritis or traveler’s diarrhea

50
Q

Treatment: Non-pharmacologic

General

A

Prevent dehydration by correcting fluid & electrolyte imbalances
Cornerstone of treatment for all types of diarrhea

51
Q

Treatment: Non-pharmacologic

Mild cases

A

Mild cases

Oral fluids and easily digestible foods

52
Q

Treatment: Non-pharmacologic

Severe dehydration

A

Severe dehydrating watery diarrhea & dysenteric diarrhea

  • IV rehydration
  • Antibiotics and antimotility agents may be needed
53
Q

Treatment: Antimicrobial therapy

Caution

A

Indiscriminate use causes resistance

Increased fluoroquinolone resistance in Campylobacter

Multidrug resistance in Salmonella spp.

54
Q

Treatment: Antimicrobial therapy

When is antibiotic use recommended?

A

Moderate to severe cases of traveler’s diarrhea
Most cases of febrile dysenteric diarrhea (except EHEC)
Culture-proven bacterial diarrhea

55
Q

Treatment: Antimicrobial therapy

A

Antibiotic therapy is specifically NOT recommended in EHEC diarrhea as it may increase the risk of hemolytic uremic syndrome (HUS)

56
Q

Treatment: Antimicrobial therapy
General information
Consider susceptibility patterns

A

Cholera: Azithromycin instead of ciprofloxacin in areas of high fluoroquinolone resistance

57
Q

ABX recommended in severe cases of cholera and ETEC

A

Cholera
-ABX shorten the duration of diarrhea, decrease fluid loss, and shorten duration of the carrier state
ETEC
-empiric ABX reduce severity and duration of diarrhea
-Short course of fluoroquinolone is the most commonly recommended therapy
-Rifaximin has been effective for ETEC for travel in Mexico

58
Q

Treatment: Antimicrobial therapy

Cholera

A

Azithromycin

59
Q

Treatment: Antimicrobial therapy

ETEC

A

fluoroquinolone

60
Q

Treatment: Antimicrobial therapy

ETEC travelers diarrhea

61
Q

Treatment: Antimicrobial therapy
Enterotoxigenic E. Coli (ETEC)
Children

A

Azithromycin 10 mg/kg/day PO once daily for 3 days; ceftriaxone 50 mg/kg/day given IV once daily for 3 days

62
Q

Treatment: Antimicrobial therapy
Enterotoxigenic E. Coli (ETEC)
Adults

A

Ciprofloxacin 750 mg PO once daily x 1-3 days.

Alternatives: rifaxamin 200 mg PO TID x 3 days; azithromycin 1G PO x 1 dose or 500 mg PO once daily x 3 days

63
Q

Treatment: Antimicrobial therapy
Vibrio cholerae 01
Children

A

Erythromycin 30 mg/kg/day divided every 8 hrs PO x 3 days; azithromycin 10 mg/kg/day PO once daily for 3 days

64
Q

Treatment: Antimicrobial therapy
Vibrio cholerae 01
Aldults

A

Doxycycline 300 mg PO x 1 day.

Alternatives: tetracycline 500 mg PO QID x 3 days; erythromycin 250 mg PO every 8 hrs x 3 days; azithromycin 500 mg PO once daily x 3 days

65
Q

Treatment: Antimicrobial therapy
General information
Shigellosis:

A

ABX therapy is reserved for the elderly, immunocompromised patients, children in daycare centers, malnourished children, and healthcare workers

In the U.S. Shigella remains susceptible to fluoroquinolones (FQ)

Azithromycin may be a better choice in other countries

66
Q

Treatment: Antimicrobial therapy

Nontyphoid Salmonella

A

Leads to bacteremia in ~8% of healthy adults

High risk patients should be treated with ABX if diagnosis is made

High risk patients include:

  • Infants < 1 yrs
  • Persons > 50 yrs
  • Immunodeficiency (AIDS)
  • Sickle cell DZ, vascular abnormalities, chemotherapy induced bowel DZ, prosthetic joints

If the organism is isolated
- Perform resistance treating

67
Q

Treatment: Antimicrobial therapy
Dysenteric Diarrhea
Shigella species
Children

A

Azithromycin 10 mg/kg/day PO once daily x 3 days; ceftriaxone 50 mg/kg/day given IV once daily for 3 days

68
Q

Treatment: Antimicrobial therapy
Dysenteric Diarrhea
Salmonella nontyphoidal
Children

A

Ceftriaxone 100 mg/kg/day divided IV every 12 hrs x 7-10 days; azithromycin 20 mg/kg/day PO once daily x 7 days

69
Q

Treatment: Antimicrobial therapy
Dysenteric Diarrhea
Shigella species
Adults

A

Ciprofloxacin 750 mg PO once daily x 3 days; levofloxacin 500 mg PO once daily x 3 days. Alternatives: azithromycin 500 mg PO once daily x 3 days

70
Q

Treatment: Antimicrobial therapy
Dysenteric Diarrhea
Salmonella nontyphoidal
Adults

A

Ciprofloxacin 750 mg PO once daily x 7-10 days; levofloxacin 500 mg PO once daily x 7-10 days. Alternatives: azithromycin 500 mg PO once daily x 7 days. For immunocompromised patients, duration should be increased to 14 days for both fluoroquinolones and azithromycin

71
Q

Treatment: Antimicrobial therapy
First choice antibiotic in ADULTS
ETEC

A

Ciprofloxacin 750 mg PO once daily x 1-3 days

72
Q

Treatment: Antimicrobial therapy
First choice antibiotic in ADULTS
Shigella spp.

A

Ciprofloxacin 750 mg PO once daily x 3 days

73
Q

Treatment: Antimicrobial therapy
First choice antibiotic in ADULTS
Salmonella nontyphoidal

A

Ciprofloxacin 750 mg PO once daily x 7-10 days

74
Q

Treatment: Antimicrobial therapy
First choice antibiotic in ADULTS
Vibrio cholerae 01

A

Doxycycline 300 mg PO x 1 day

75
Q

Treatment: Antimicrobial therapy
First choice antibiotic in CHILDREN
ETEC

A

Azithromycin 10 mg/kg/day PO once daily for 3 days

76
Q

Treatment: Antimicrobial therapy
First choice antibiotic in CHILDREN
Shigella spp.

A

Azithromycin 10 mg/kg/day PO once daily x 3 days

77
Q

Treatment: Antimicrobial therapy
First choice antibiotic in CHILDREN
Salmonella nontyphoidal

A

Azithromycin 20 mg/kg/day PO once daily x 7 days

78
Q

Treatment: Antimicrobial therapy
First choice antibiotic in CHILDREN
Vibrio cholerae 01

A

Azithromycin 10 mg/kg/day PO once daily for 3 days

79
Q

Antimotility agents (i.e. diphenoxylate/atropine; loperamide)

A

Offer symptomatic relief in watery diarrhea by reducing the number of stools

Slowing of fecal transit time may result in extended toxin-associated damage, worsening symptoms, and complications

Avoid antimotility agents in toxin-mediated dysenteric diarrhea (i.e. EHEC; shigellosis)

80
Q

Treatment: Food Poisoning

Clostridium botulinum

A

Respiratory support
Botulinum antitoxin
Equine globulins obtained from horses immunized with toxins A, B, and E
If evaluation occurs within hrs of ingestion:
Gastric lavage & induction of vomiting (to remove toxin)
Cathartics and enemas (to remove toxin)

81
Q

Watery Diarrhea

Norovirus: Sx

A

Nausea, vomiting diarrhea, abdominal cramps, myalgia

82
Q

Watery Diarrhea

Norovirus: Tx

A

Supportive care

83
Q

Watery Diarrhea

Rotavirus: Sx

A

Nausea, vomiting, diarrhea, fever, abdominal pain, lactose intolerance

84
Q

Watery Diarrhea

Rotavirus: Tx

A

Supportive care

85
Q

Watery Diarrhea

Vibrio cholerae: Sx

A

Profuse watery diarrhea, vomiting, and leg cramps; Death can work within hours without treatment

86
Q

Watery Diarrhea

Vibrio cholerae: Tx

A

Antibiotics + Supportive Care

DOC: doxycycline Alternatives: tetracycline, erythromycin, azithromycin

87
Q

Watery Diarrhea
Enterotoxigenic
E. coli (ETEC) : Sx

A

Watery diarrhea and abdominal cramping

Responsible for ½ of all E. coli diarrheal illness; common cause of food/water outbreaks

88
Q

Watery Diarrhea
Enterotoxigenic
E. coli (ETEC): Tx

A

Antibiotics + Supportive Care
DOC: ciprofloxacin
Alternatives: rifaxamin, azithromycin

89
Q

Dysentery
Entero-hemorrhagic
E. coli (EHEC): Sx

A

Gastroenteritis, enterocolitis, sometimes bloody diarrhea and hemolytic-uremic syndrome

90
Q

Dysentery
Entero-hemorrhagic
E. coli (EHEC): Tx

A

Supportive Care

No ABX!!!!

91
Q

Dysentery

Salmonella nontyphoidal: Sx

A

Diarrhea (sometimes bloody), fever, and abdominal cramps

92
Q

Dysentery

Salmonella nontyphoidal: Tx

A

Antibiotics + Supportive Care
DOC: Ciprofloxacin and Levofloxacin
Alternatives: azithromycin

93
Q

Dysentery

Shigella spp.: Sx

A

Watery or blood diarrhea (8-10 stools/day), severe abdominal pain, fever, and malaise

94
Q

Dysentery

Shigella spp.: Tx

A

Antibiotics + Supportive Care
DOC: Ciprofloxacin and Levofloxacin
Alternatives: azithromycin

95
Q

Dysentery

Clostridium botulinum: Sx

A

Double vision, blurred vision, drooping eyelids, slurred speech, difficulty swallowing, dry mouth, and muscle weakness

96
Q

Dysentery

Clostridium botulinum: Tx

A

Respiratory support, botulinum anti-toxin

Infectious Disease (56 decks)

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