Diarrhea


Agent

Brief clinical tidbits

Treatment

Campylobacter, Shigella, Salmonella, Yersinia

Invasive diarrhea characterized by fever, bloody stools

TMP/SMX or fluoroquinolone for 3 days (may reduce duration of shedding); see below for more information regarding Campylobacter

Enterotoxigenic E. coli, Campylobacter, Salmonella, Shigella, Aeromonas, Vibrio, Bacteroides

Traveler’s diarrhea: watery diarrhea, ± abdominal cramps, N/V, tenesmus

TMP/SMX or fluoroquinolone for 3 days may reduce duration of illness by 2–3 days

Shigella

Severe dysentery with fever, bloody diarrhea

TMP/SMX or fluoroquinolone two times a day for 3 days

Vibrio cholera

“Rice-water stools,” severe diarrhea

Doxycycline 300 mg × 1 dose, or TMP/SMX two times a day for 3 days or fluoroquinolone × 1 dose

Campylobacter

Associated with Guillain-Barre, inflammatory bowel disease and reactive arthritis. Causes acute watery diarrhea

Azithromycin 500 mg a day for 3 days

Salmonella

Treat specific patient populations (see below)

TMP/SMX or fluoroquinolone two times a day for 5–7 days

Listeria

Treat specific patient populations (see below)

Ampicillin

C. difficile

See below

Metronidazole 500 mg orally three times a day for 10–14 days or vancomycin 125 mg orally four times a day for 10–14 days


TMP/SMX trimethoprim/sulfamethoxazole




Table 18.2
Antibiotic choices for specific protozoal agents
































Agent

Brief clinical tidbits

Treatment

Giardia

Persistent diarrhea after exposure to untreated water; relapses may occur due to misdiagnosis

Metronizadole 750 mg three times a day for 7–10 days

Entamoeba histolytica

Severe disease may result in hepatic abscess

Metronizadole 750 mg three times a day for 5–10 days in addition to paromomycin 25–35 mg/kg in three divided doses for 5–10 days

Cryptosporidium

Therapy may be required in immunosuppressed patients but may not be necessary in immunocompetent patients with mild disease and those patients with HIV who have a CD4 count >150 cells/mm3

Nitazoxanide 500 mg two times a day for 3 days for severe disease

Cyclospora or Isospora

Requires longer therapy in HIV or immunosuppressed

TMP/SMX two times per day for 7–10 days (2–4 times per day for 10–14 days for HIV or immunosuppressed)

Microsporidia

In patients with AIDS, highly active retroviral therapy may be adequate to eradicate intestinal disease

Albendazole 400 mg two times per day for 3 weeks



Pitfalls




  1. 1.


    Treating patients who have bloody diarrhea with abdominal pain and no fever and relevant history of eating raw ground beef or seed sprouts with antibiotics:


    1. (a)


      There is a risk of hemolytic-uremic syndrome.

       

    2. (b)


      Treatment with antibiotics does not improve O157 illness.

       

     

  2. 2.


    Treatment of Yersinia. These patients present with “pseudoappendicitis” with right lower quadrant abdominal pain along with the watery diarrhea. Treatment is only required for immunocompromised patients.

     

  3. 3.


    Routine treatment of Salmonella. These patients may present acutely ill with fever and muscle aches and pains, and it typically is human-to-human transmission. Treatment is recommended for those patients who are:


    1. (a)


      Immunocompromised

       

    2. (b)


      Are at the extremes of age

       

    3. (c)


      Have persistent, severe diarrhea

       

    4. (d)


      Have severe illness, including sepsis

       

    5. (e)


      Have a history of valvular heart disease

       

     

  4. 4.


    Routine treatment of Listeria. Unless pregnant or immunocompromised – in which case the disease may be severe – patients typically have mild systemic symptoms.

     



18.9.2 Treatment of Clostridium Difficile


This organism deserves special mention as it is one of the more serious causes of diarrhea affecting patients. Prior antibiotic use (including fluoroquinolones, clindamycin, penicillins, and cephalosporins) eliminates normal gut flora allowing for colonization by C. difficile. The diarrhea caused by C. difficile is severe, with up to 15 bowel movements per day with associated abdominal pain and cramping. Many patients may have a systemic reaction, with fever, tachycardia, and tachypnea depending on level of dehydration and overall illness. Complications of C. difficile infection include toxic megacolon, which is an abnormal dilation of the colon that is seen on imaging studies. Those patients who do not respond to medical management may require urgent surgical consultation due to the high risk of perforation.

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Nov 20, 2017 | Posted by in Uncategorized | Comments Off on Diarrhea

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