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“Don’t Drink the Water”: A Primer on Infectious Diarrhea Patty W. Wright, MD with appreciation...
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Transcript of “Don’t Drink the Water”: A Primer on Infectious Diarrhea Patty W. Wright, MD with appreciation...
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“Don’t Drink the Water”: A Primer on Infectious Diarrhea
Patty W. Wright, MDwith appreciation to Ban Allos, MD
March 2011
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Objectives
To familiarize participants with the causes, diagnostic work-up, and treatment of the most common etiologies of infectious diarrhea.
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Foodborne-related Illness and Death in the U.S.
Events per year Number
Illnesses >76 million
Hospitalizations >325,000
Deaths >5,000
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Common Food- and Water-borne Pathogens Causing Diarrhea in the US
Salmonella Campylobacter Shigella Listeria Vibrio E. coli O:157 Bacillus Clostridium S. aureus
Rotaviruses Norwalk-like viruses Cyclospora Isospora Cryptosporidium Giardia
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Case 1
A 19 year old female college student presents to the ED at 5 pm c/o the acute onset of N/V with abdominal cramps and mild diarrhea. She denies associated fevers. She ate at a local restaurant today at noon. She reports that several of her classmates have been ill over the past week with the “stomach flu”.
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Case 1
What pathogens are on your differential?
What diagnostic work-up would you perform?
How would you treat the patient?
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Acute N/V +/- Diarrhea: Pathogens
Pathogens that have preformed toxins – Cause onset of symptoms within 1-6 hours
of ingestion– S. aureus – Bacillus cereus (short-incubation)
“Winter Vomiting Disease”– Norwalk-like viruses– Rotavirus
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Acute N/V +/- Diarrhea:Dx and Rx
Typically resolves within 12-24 hrs, without specific therapy
No diagnostic work-up required Treat with anti-emetics and hydration,
if needed
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Classic Association/Outbreak
Staphylococcus aureus – ham, cream-filled pastries
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Classic Association/Outbreak
Norwalk-like viruses – cruise ships, raw seafood
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Case 2
A 45 year old male develops nausea, diarrhea, and abd cramps at bedtime. He denies any associated vomiting, fever, or blood in his stool. He reports that a friend from work, who at lunch with him at a local Chinese restaurant, is also ill with similar symptoms.
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Case 2
What pathogens are on your differential?
What diagnostic work-up would you perform?
How would you treat the patient?
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Acute Diarrhea w/o Vomiting/Fever Pathogens that produce toxins in vivo
– Bacillus cereus (long-incubation)– Clostridium perfringens
Typically resolves within 24 – 48 hrs, without specific therapy
No diagnostic work-up required Treat symptomatically
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Classic Association/Outbreak
Bacillus cereus – fried rice
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Case 3
A 56 year old male with HTN presents to the clinic with a 2 day h/o diarrhea, abd cramps, and fever to 101. He denies blood in his stool or N/V. His wife also reports diarrhea over the past 24 hours. He denies any recent hospitalizations or antibiotic usage.
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Case 3
What pathogens are on your differential?
What diagnostic work-up would you perform?
How would you treat the patient?
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Acute Diarrhea and Fever w/o Bloody Stool Pathogens that cause tissue invasion
– Salmonella– Shigella– Campylobacter– Vibrio– Invasive E coli– Listeria
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Acute Diarrhea and Fever w/o Bloody Stool For diarrhea > 1 day in duration or
severe (dehydration, fever, blood)– Obtain additional exposure history– Check fecal WBC
If + fecal WBC– Stool culture for pathogens– Consider testing for C diff toxin – Consider empiric abx (adults only)
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Acute Diarrhea and Fever w/o Bloody Stool Treatment:
– Hydration– Quinolones typically empiric treatment of
choice for food-borne diarrhea– Azithromycin is alternative if cannot take
quinolones or risk of resistant Campylobacter
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Classic Association/Outbreak
Salmonella – peanut butter
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Classic Association/Outbreak
Salmonella and Campylobacter – poultry and poultry products
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Classic Association/Outbreak
Vibrio – raw oysters (or wading in the Gulf of Mexico), especially in patients with hepatic dysfxn
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Classic Association/Outbreak
Listeria – refrigerated food items (cold cuts, prepared salads), soft cheeses
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Classic Association/Outbreak
Shigella – low infectious dose (10-100 organisms), “cool, moist foods that require much handling after cooking”,
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Classic Association/Outbreak
Yersinia – pork, chitterlings
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Case 4
A 23 year old female presents to the ED with 3 days of diarrhea. She reports that she initially had watery diarrhea, but that it has now turned grossly bloody. She reports severe abd cramps. She denies fever or N/V.
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Case 4
What pathogens are on your differential?
What diagnostic work-up would you perform?
How would you treat the patient?
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Acute Bloody Diarrhea +/- Fever
Pathogens that produce shiga toxin– Shigella dysenteriae– E coli O157:H7
Evaluation:– Fecal WBC– Stool culture for pathogens (including
E coli O157:H7)– Consider testing for C diff toxin– CBC with diff, BMP
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Acute Bloody Diarrhea +/- Fever Treatment
– NaCl hydration and supportive care– AVOID antibiotics (especially trim-sulfa)– AVOID antimotility agents in all patients
with diarrhea and• High fever or• Bloody diarrhea or• Fecal WBC’s
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Hemolytic Uremic Syndrome (HUS)
Occurs in about 10% of pts with E coli O157:H7
Begins ~ 5-10 days after symptom onset Triad of microangiopathic hemolytic anemia,
thrombocytopenia, and acute renal failure Most common in kids < 4 yrs old Mortality rate 5-15% Older children and adults have poorer
prognoses Na load most protective factor in the
prevention of HUS in pts with E coli O157:H7
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Classic Association/Outbreak:E. coli O157:H7
1.Food-Foods of bovine origin (hamburger, milk, etc.)-Fruits (apple cider) and vegetables contaminated with manure
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Classic Association/Outbreak:E. coli O157:H7
2.Water-Contaminated drinking water-Swimming in contaminated pools and lakes
3.Direct person-to-person or animal-to-person spread-Daycare centers-Long-term care facilities -Petting zoos
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Case 5
A 37 year old male presents to the clinic c/o 4 weeks of daily diarrhea with associated anorexia, fatigue, bloating, and nausea. He denies fevers, vomiting, or blood in his stool. He has lost about 7 pounds over the past month. He denies recent travel.
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Case 5
What pathogens are on your differential?
What diagnostic work-up would you perform?
How would you treat the patient?
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Chronic Diarrhea (Non-bloody)
Etiologies– Parasites– Tropical Sprue– Bacterial overgrowth syndromes– Non-infectious causes
• Food allergies• Neoplasm and endocrine processes• Functional disorders
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Chronic Diarrhea (Non-bloody)
Most common parasitic causes in US– Giardia– Cryptosporidium– Cyclospora– Isospora
Giardia photos: http://phil.cdc.gov/phil/details.asp
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Chronic Diarrhea (Non-bloody) Diagnosis:
– Fecal WBC– Wet mount for ova and parasites– Modified acid-fast stain to detect
• Cyclospora• Isospora• Cryptosporidium
– Giardia antigen testing (stool)– HIV antibody testing
Treatment specific for pathogen isolated
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Classic Association/Outbreak
Cryptosporidium – drinking water contaminated with manure after flooding
Cyclospora – raspberries contaminated with bird feces
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Chronic Bloody Diarrhea
Inflammatory Bowel Disease (ulcerative colitis or Crohn's disease) most common cause
Differential includes bowel ischemia, colon cancer, or polyps
Infectious causes possible, but much less likely
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Case 6
A 68 year old female with chronic sinusitis presents with fever to 100.7, malaise, abdominal pain, and severe diarrhea which started yesterday. She reports having 20 watery, non-bloody stools since her diarrhea began. Her current medications include a steroid nasal spray, loratidine, and omeprazole.
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Case 6:
What pathogens are on your differential?
What diagnostic work-up would you perform?
How would you treat the patient?
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Clostridium difficile- Associated Disease
Risk Factors for CDAD:– Antibiotic exposure
• Any abx within the prior 2 months– Prolonged hospitalization– Severity of underlying disease– Age > 65 years– GI surgery– PPI
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Clostridium difficile- Associated Disease Spectrum of Disease
– Asymptomatic carrier– Diarrhea without colitis– Colitis without pseudomembranes– Pseudomembranous colitis– Fulminant colitis
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Clostridium difficile- Associated Disease
Pseudomembranous Colitis
www.faculty.plattsburgh.edu
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Clostridium difficile- Associated Disease Fulminant colitis
– About 3% of cases– Signs and Symptoms
• Diffuse abd tenderness/distention, diarrhea, low BP, high fever, leukocytosis
– Complications • Ileus, toxic megacolon, bowel
perforation, death
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Clostridium difficile- Associated Disease
Diagnosis– ELISA testing for toxins A and B
• May need to repeat to improve sensitivity
– Cytotoxicity assays• “Gold Standard”, but expensive & requires 48 hrs
– Culture for C. diff• Does not distinguish disease from colonization
– Colonoscopy• Risk for perforation
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Clostridium difficile- Associated Disease Treatment of mild disease
– Metronidazole po 500mg Q8hrs x 10-14 days
Treatment of moderate to severe disease (WBC > 15k or increasing cr)
– Vancomycin po 125mg Q6hrs x 10-14 days
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Clostridium difficile- Associated Disease Treatment of severe disease
(hypotension, obstruction, ileus, or perforation)– Metronidazole iv 500mg Q8hrs and
vancomycin via NGT 500mg Q6hrs and/or vancomycin enema
– Surgical consult• Consider colectomy if rising WBC and
lactate
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Clostridium difficile- Associated Disease Recurrence
– Occurs in 5-30% of patients– Rate does not vary with initial agent used– Can consider re-treatment with same agent– Consider vancomycin po pulse dosed
(125-500mg Q 3days x 3 wks) or tapered – ? Role of cholestyramine and probiotics
ELISA not recommended as a test of cure in asymptomatic pts
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Clostridium difficile- Associated Disease Prevention and Control
– Avoid unnecessary antibiotic use– Hand washing with soap and water
• Avoid alcohol-based hand sanitizers for hand hygiene after seeing patients with known or suspected C. diff
– Contact precautions for hospitalized pts– Clean pt environment with 1:10 dilution
of bleach
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Summary- Diarrhea
Acute diarrhea with N/V will typically resolve within 24-48 hrs without rx
If diarrhea persists or is severe, evaluate with fecal WBC, cx, +/- C. diff
Hydration and supportive care +/- abx for treatment
Evaluate for parasites and HIV if chronic diarrhea
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Summary- CDAD
Wide spectrum of disease states Dx with ELISA testing for toxins A and B Rx mild disease w/ po metronidazole;
Rx severe disease w/ po vancomycin; Rx w/ iv metro and NGT/pr vanc, if ileus
Recurrence is common Use hand washing and contact
precautions to prevent spread
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