GI Infections

Question 1

In which patients should you send a stool O&P (3)?

Answer 1

Diarrhea > or = 14 days
Immunocompromised w/diarrhea
Travel

Question 2

In which patients with diarrhea should you send stool cultures (4)?

Answer 2

Fever
Bloody or mucous stools
Severe abdominal pain
Sepsis

Question 3

What are the enteric pathogens that cause bloody diarrhea?

Answer 3

Salmonella
Shigella
Campylobacter
Yersinia 
STEC

Question 4

In which patients with bloody diarrhea is empiric antimicrobial therapy warranted?

Answer 4

1. Sick immunocompetent patients with bacillary dysentery (frequent, scant bloody stools, abdominal pain, tenesmus, fevers), suggestive of Shigella.
2. Recent travel with high fevers (> or = 38.5) and/or sepsis.
3. Sick immunocompromised patients

Question 5

What are the empiric antibiotics for bloody diarrhea?

Answer 5

Azithromycin

Ciprofloxacin

Question 6

What are the treatment options for Campylobacter?

Answer 6

Azithromycin (1st line)

Ciprofloxacin (alternative)

Question 7

What are the treatment options for diarrhea caused by Salmonella?

Answer 7

1st Line - CTX or Ciprofloxacin

2nd Line - Ampicillin or Septra or Azithromycin

Question 8

What is the first line therapy for Vibrio cholerae?

Answer 8

Doxycycline

Question 9

What is the first line therapy for diarrhea caused by Yersinia enterocolitica?

Answer 9

Septra

Question 10

What is the first line therapy for diarrhea caused by Shigella?

Answer 10

Azithromycin OR Ciprofloxacin OR CTX

Question 11

What are the criteria for severe C. Difficile?

Answer 11

WBC > or = 15
Cr 1.5 x pre-morbid levels

Other Considerations - age > 65, immunosuppression, T > 38, albumin < 30, peritonitis

Question 12

What are the criteria for complicated C. Difficile (5)?

Answer 12

Sepsis
Shock
Ileus
Perforation
Toxic Megacolon (colonic dilation > 6 cm)

Question 13

What is the treatment of severe, complicated C. Difficle?

Answer 13

Vancomycin 125-500 mg PO QID + metronidazole 500 mg IV Q8H +/- PR vancomycin if paralytic ileus.

Question 14

How do you treat of first relapse of C. Difficle?

Answer 14

Vancomycin 125 mg PO QID 10-14d

OR

Fidaxomicin 200 mg PO BID x 10 days if severe or complicated

Question 15

How would you treat a second relapse of C. Difficile?

Answer 15

Vancomycin in a taper and/or pulsed regimen. Consider referral for fecal transplant.

Question 16

In which patients with intra-abdominal abscess might you consider trial of antimicrobial management only?

Answer 16

If 3 cm or less in size.

Question 17

How would you manage a community acquired, intra-abdominal infection?

Answer 17

(1) Ceftriaxone OR Ciprofloxacin
PLUS:
(2) Metronidazole

Question 18

Which antimicrobial regimen would you use to treat an intra-abdominal infection if health-care associated or critically ill?

Answer 18

(1) Pseudomonas Coverage - Piptazo, meropenem, ceftazidime or ciprofloxacin.
PLUS:
(2) Metronidazole
+/-
(3) Enterococcal Coverage: Vancomycin - consider if immunocompromised, post-operative, or if valvular heart disease/intra-vascular prosthesis.

Question 19

When should you add anti-fungal coverage to treat intra-abdominal infection?

Answer 19

ONLY if Candida isolated.

Empiric coverage otherwise does not improve mortality.

Question 20

What did the STOP-IT trial demonstrate?

Answer 20

If source control is achieved, 3-5 days of antibiotics has similar outcomes to continuing until 2 days after resolution of fever, leukocytosis and ileus.