GI: Non-Blood Diarrhea Flashcards by Meghan May

What labs do we order for acute onset, non toxic, non-bloody diarrhea

dont need to order them

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What medications can cuse acute non-bloody diarrhera

Medications (some with osmotic effect)
– Sorbitol (gum, mints, pill fillers)
– Mannitol
– Fructose (fruits, soft drinks)
– Fiber (bran, fruits, vegetables)
– Lactulose

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What Mg+ containing meds can cause acute, non bloody diarrhea

– Nutritional supplements
– Antacids
– Laxatives

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What drugs cause diarrhea through non-osmotic means

– Metformin
– Antibiotics
– Colchicine
– Digoxin
– Selective serotonin reuptake inhibitor antidepressants

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• Caliciviruses (including Norovirus)
• Rotovirus
Cause what kind of diarrhea

acute, non bloody

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• Vibrio cholera
• Escherichia coli
• Shigella species
• Salmonella species
• Campylobacter species
• Yersinia enterocolitica
Cause what kind of diarrhea?

acute, non bloody

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– Shigella species
What kind of diarrhea does this cause
– Ecoli
– Campylobacter species
– Salmonella species
– Y enterocolitica
– Klebsiella oxytoca

infectious inflammatory colitis

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What types of bacterial acute non bloody diarrhea should be considered to treat with antibiotics

Vibrio cholera
Escherichia coli
Shigella species
Salmonella species
Campylobacter species
Yersinia enterocolitica

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What types of Infectious diarrhea from inflammatory colitis can be tx with antibiotics

– Shigella species
– Ecoli
– Campylobacter species
– Salmonella species
– Y enterocolitica
– Klebsiella oxytoca

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Drug that Inhibits DNA gyrase and/or topoisomerase IV

quinolones, e.g. ciprofloxacin

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Binds 50S ribosomal subunit, blocking mRNA translocation,

e.g. azithromycin, erythromycin

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What meds do we treat campylobacter jejunum with?

Ciprofloxacin (quinolones)

Macrolides (azithromycin)

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Campylobacter is inherently resistant to

penicillins, most cephalosporins, trimethoprim

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Pro kinetic, risk for arrythmias and cardiac arrest, lots of CYP3A inhibition and more frequent dosing needed

erythromycin

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Low incidence of GI effects, lower incidence of cardiac effects, few drug interactions, less frequent dosing

Azithromycin

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What are we seeing increasing drug resistance to for campylobacter?

Ciprofloxacin

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Gram-neg rods
Facultative anaerobes
Members of the Enterobacteriaceae family
B-lactamase (often transmissable) has become quite common in this family

Shigella and Salmonella

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What drugs are approved to tx Shigella and Salmonella

Ampicillin (both)
TMP/SMX (Shigella)~ dont use this much
Ciprofloxacin (both)

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Why is trimethoprim sulfate a bad choice to tx Shigella or Salmonella?

high drug resistance

use Ciprofloxacin or Azithromycin (not yet approved, but works great)

This march we saw increasing outbreak of Shigella sonnei restistant strain to which drug?

Ciprofloxacin

shigella is high contagious and can be carried for weeks/months

What is a key barrier to infection with enteric pathogens like Salmonella?

NOrmal flora

Pt had acute non bloody diarrhea and was tx with Amoxicillin for 5 days. Come to ED with bloating, pain, bloody diarrhea 6-8 x/day with low grade fevers. What test should we order?

Stool testing for C.Diff!

What two drugs are best choice to tx C.diff?

Vancomycine and Fidacomicin

Metronidazole is commonly used, but not FDA approved

What type of bug is C.Diff?

Gram +
anerobe
spore forming

What drug is a common cause of C.diff infections?

Clindamycin!

Why can't we use cefepime and clindamycin for C.Diff?

they work for some anaerobes, not C.Diff

Pt has C.diff and you culture it.. you find Mutations in RNA polymerase B (rpoB) What drug will have decreases sensitivity for C.diff now?

Fidaxomicin

What is the mechanicms of Fidacomicin?

– Macrocyclic that blocks formation of RNA polymerase open promoter complex – No cross-resistance with other RpoB inhibitors (e.g. rifamycins)

explain why we see metronidazole resistance in C.diff

– often transient, lost in storage, or after freeze/thaw – Some changes noted in electron transport, energy generation, iron utilization – No association with mutations in nitroreductase

Explain why we see Vancomycin resistance in C.Diff

– Not common, diverse mutations, not well-defined – In vitro resistance studies: mutations in various cell wall enzymes (N-acetylglucosamine transferase, L-serine deaminase), but no clinical link

What are three different times we see C.Diff infections?

relapse with original, re-infection with another strain or antibx use that fucks with normal flora

What is the coverage spectrum for Metronidazole

Anaerobes: both +/-

What is the coverage spectrum for Clindamycin

gram + aerobes; | gram+/- anerarobes

What is the coverage spectrum for fidaxomicin

– Primarily Clostridium only – Some effects on Peptostreptococcus – No effects on other gram-pos. (Enterococcus, Streptococcus, Lactobacillus, Bifidobacterium) or gram-negs

What is the coverage for Vancomycin

Many gram +(aerobes and anaerobes)

Which leads to less recurrance of C.Diff: vancomycin or fidoxomicin?

Fidoxomicin

What is the reason that Fidoxomicin has less recurrence to C.Diff then Vancomycin

* less disruption of normal flora * cidal (time-dependent) vs. static effect of vancomycin on C. diff. * fidaxomicin has an active metabolite OP-1118 * fidaxomicin has post-antibiotic effect (6–10 hr)

What side effect will you see when tx pt with ORAL vancomycin for C.Diff and why?

Nausea and abdominal pain: d/t poor absorption which is what we want, then targets the colon and is highly concentated

What side effects do we see with IV vancomycin

red man, ototoxic, nephrotoxic and phlebitis at injection site

What drug can be given IV to treat C.Diff?

Metronidazole: enough metronidazole is excreted in bile and there is increased exudation across intestinal mucosa during CDI For severe CDI: IV metronidazole can be added to oral vancomycin

Pt is being tx with metronidizole for 3 days for C.Diff infection; now has fever of 102, tachycardia, no BM in 24 hrs, with distended abdomen and + rebound and guarding; on xray the colon is large, distended and lack haustra. What's going on?

Toxic megacolon: need to resect the colon immediately!

How does C.diff get into the large intestine

vegitative cells are killed off in the stomach d/t acid and spores move along to intestine and germinate once they are exposed to bile acids--> the mult in colon and gut mucosa faciliates adherance

Why do we get C.diff infections from antibx?

Antibx kill off gut flora, C.Diff grows and secretes toxins and ulcerates mucosa--> damaged mucosa secretes fluid = diarrhea

What do we use to tx initial episode of mild/moderate C.Diff infection?

Metronidazole, 3xs day/ po

What do we use to tx initial episode of C.Diff that is severe?

Vancomycin 4x day po

What do we use to treat initial episode of C.Dif that is severe and complicated?

Vanco 4xs day po AND metonidazole IV