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infectious diarrhea; infectious colitis

Etiology: 1) toxin production a) preformed toxin (onset of action rapid, within hours) - Bacillus cereus - Clostridium perfringens - Staphylococcus aureus - unrefrigerated meat & cream-based foods b) enterotoxin - Aeromonas - enterotoxigenic Escherichia coli - Vibrio cholera c) cytotoxin - Clostridium difficile* (pseudomembranous enterocolitis) - antibiotics - Escherichia coli O157:H7 2) enteroadherence a) cryptosporidiosis b) enteroadherent/enteropathic Escherichia coli c) Helminths d) Giardia lamblia - day care centers - travelers - campers - homosexual males - immunocompromised - lactose-intolerant patients e) amebiasis f) Cyclospora 3) mucosal invasion a) minimal (ulcers if any, clean-based) - Norwalk virus - Rotavirus - adenovirus - astrovirus - calcivirus - coronavirus - cytomegalovirus (immunosuppression: organ transplantation, AIDS) - Herpes simplex virus b) variable - Aeromonas - Campylobacter jejuni:* college students - most common cause of infectious diarrhea from undercooked poultry [12] - fever, abdominal cramping - delay of symptoms 2-5 days after exposure [12] - Salmonella enteritidis* - incubation time 8-72 hours - generally bloody diarrhea with mucus - Vibrio parahaemolyticus - raw or partially-cooked seafood c) severe - Entamoeba histolytica* - homosexual males - travelers to the tropics - enterohemorrhagic Escherichia coli* - nursing homes - severely debilitated - undercooked beef - Shigella* - day care centers - Native American reservations - areas of food & water contamination - homosexual males - diarrhea usually bloody with mucus [12] - mean incubation time 3 days [12] - Yersinia - unusual cause of diarrhea [12] - may mimic appendicitis with right lower quadrant pain [12] 4) systemic infection - Legionella - Listeria monocytogenes (encephalitis, immunosuppression, dairy) - measles - psittacosis - Rocky mountain spotted fever - toxic shock syndrome - viral hepatitis 5) diarrhea in patients with AIDS * causes of bloody diarrhea or inflammatory diarrhea Laboratory: - a 72 hour observation period is generally indicated prior to diagnostic testing - exceptions are immunocompromised patients, patients sick enough to require hospitalization, bloody or inflammatory diarrhea [8], children < 5 years, & the elderly [10] - stool culture for bacterial pathogens - EIA for C difficile enterotoxin EIA ((98% sensitivity) or Clostridium difficile toxin genes in stool (PCR) - shiga toxin gene for bloody diarrhea - Norovirus RNA in stool - stool ova & parasite for giardiasis, amebiasis - Cryptosporidium antigen in stool - modified acid fast stain for Cryptosporidia, Cyclospora - rapid multiplex molecular gastrointestinal assay [8] - identifies most common bacteria, viruses, & parasites in stool - more sensitive than stool culture & microscopy with special stains - see ARUP consult [3] Special laboratory: - sigmoidoscopy Complications: - irritable bowel syndrome 2-3 years later (25-36%) Differential diagnosis: - see colitis Management: (also see acute diarrhea & ref [10]) 1) hydration - most infectious diarrhea is self-limited & resolves with supportive therapy 2) anti-motility agents contraindicated with bloody or inflammatory diarrhea* 3) antimicrobial agents: a) Campylobacter jejuni - erythromycin 250 mg PO QID for 3-5 days [8] - azithromycin (Zithropac) - ciprofloxacin (Cipro) 500 mg PO BID for 7-10 days b) Clostridium difficile - metronidazole (Flagyl) 250 mg PO QID for 10 days - avoid during pregnancy - vancomycin 125-250 mg PO QID for 5-10 days for severe or persistent diarrhea & offending antibiotic cannot be stopped c) Escherichia coli - traveler's diarrhea - azithromycin once - ciprofloxacin (Cipro) 500 mg PO BID for 3 days [8] - rifaximin for 3 days - E coli O157:H7 - supportive care only - antibiotics & antimotility agents associated with risk of hemolytic uremic syndrome [8] d) Entamoeba histolytica - metronidazole (Flagyl) 750 mg PO TID for 10 days followed by: - iodoquinol 650 mg PO TID for 20 days to eliminate cyst phase (avoid if patient is allergic to iodine) e) Giardia lamblia - quinacrine (Atrabine) 100 mg PO TID for 5 days - furazolidine (Furoxone) 100 mg PO QD for 7 days - metronidazole (Flagyl) 250 mg PO TID for 7 days f) Salmonella enteritidis - treat only if immunocompromised, bacteremic (septic) or < 1 year of age - ciprofloxacin (Cipro) 500 mg PO BID for 7 days + ceftriaxone [8] - Bactrim DS PO BID for 5 days - adjust dosage for child < 1 year of age g) Shigella - Bactrim, Septra DS PO BID for 5 days - ciprofloxacin (Cipro) 500 mg PO BID for 3 days [8] - norfloxacin (Noroxin) 800 mg PO once - azithromycin for 3 days [8] h) Yersinia - fluoroquinolone for 3 days - TMP/SMX for 3 days i) Vibrio - fluoroquinolone for 3 days - azithromycin for 3 days j) Cryptosporidium - supportive care k) Cyclospora - TMP/SMX l) cytomegalovirus (CMV) in immunosuppressed patients - organ transplantation, HIV1 infection (AIDS) - ganciclovir 5 mg/kg BID IV - valganciclovir 900 mg BID (dosage adjustment for renal insufficiency) 4) probiotics may be useful for shortening the duration of acute infectious diarrhea (1 day shorter) [7] * toxic megacolon is a complication

Related

acute diarrhea

Specific

Clostridium difficile enterocolitis; C difficile-associated diarrhea (CDAD, CDD) diarrhea in patients with AIDS dysentery pseudomembranous enterocolitis typhoid (enteric) fever

General

diarrhea gastrointestinal infection colitis

References

  1. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 237
  2. Marshall JK et al, Incidence and epidemiology of irritable bowel syndrome after a large waterborne outbreak of bacterial dysentery. Gastroenterology 2006, 131:445 PMID: 16890598
  3. ARUP Consult: Diarrhea https://arupconsult.com/content/diarrhea
  4. ARUP Consult: Diarrhea, Parasitic Evaluation deprecated reference
  5. ARUP Consult: Diarrhea, Viral Evaluation deprecated reference
  6. Guerrant RL, Van Gilder T, Steiner TS Practice guidelines for the management of infectious diarrhea. Clin Infect Dis. 2001 Feb 1;32(3):331-51 PMID: 11170940
  7. The NNT: Probiotics for Acute Infectious Diarrhea. http://www.thennt.com/nnt/probiotics-for-acute-infectious-diarrhea/ - Allen SJ, Martinez EG, Gregorio GV, Dans LF. Probiotics for treating acute infectious diarrhoea. Cochrane Database Syst Rev. 2010 Nov 10;(11):CD003048 PMID: 21069673
  8. Medical Knowledge Self Assessment Program (MKSAP) 17, 18 American College of Physicians, Philadelphia 2015, 2018.
  9. DuPont HL. Approach to the patient with infectious colitis. Curr Opin Gastroenterol. 2012 Jan;28(1):39-46. Review. PMID: 22080825
  10. Shane AL, Mody RK, Crump JA et al 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clinical Infectious Diseases. October 19, 2017 PMID: 29053792 https://academic.oup.com/cid/article/doi/10.1093/cid/cix669/4557073/2017-Infectious-Diseases-Society-of-America - Infectious Disease Society of America IDSA Infectious Diarrhea guidelines recommend when to test, when to treat. EurkAlert. Oct 19, 2017 https://www.eurekalert.org/pub_releases/2017-10/idso-iid101817.php - Anello J, Feinberg B, Lindsey R et al Infectious Diarrhea Clinical Practice Guidelines, December 2017 Medscape. Dec 6, 2017 https://reference.medscape.com/viewarticle/889632_8
  11. Hamilton KW, Cifu AS Diagnosis and Management of Infectious Diarrhea. JAMA. Published online February 14, 2019 PMID: 30763429 https://jamanetwork.com/journals/jama/fullarticle/2725406
  12. NEJM Knowledge+ Gastroenterology