Common infectious diseases

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Common infectious diseases

• Piroon Mootsikapun M.D.
• ID unit, Department of Medicine Faculty of
  Medicine, KKU

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Acute infectious diarrhea
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• T 37 C, BP 100/70 HR 100 RR 24/min
• Mild dehydrate
• Tender at epigastrium, distended abdomen,
  increased bowel sound

Diagnosis food poisoning
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• T 37 C, BP 90/60 HR 100 RR 24/min
• Marked dehydrate
• increased bowel sound, not tender
• Stool exam watery

Diagnosis Cholera-like severe diarrhea
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• T 39 C, BP 100/70 HR 100 RR 24/min
• Moderate dehydrate
• decreased bowel sound, distended abdomen

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Diagnosis Infective diarrhea
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Acute infectious diarrhea

• Inflammatory (invasive) diarrhea
• - Shigella
• - Salmonella
• - Plesiomonas shigelloides
• Non-inflammatory (toxin induced) diarrhea
• - Vibrio cholerae
• - Enterotoxigenic E. coli
• - Bacillus cereus

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Routine management

• IV fluid -5D/NSS
• CBC, BS, BUN, Cr, E lyte
• Hemo c/s x 2 spp.
• Stool exam
• Rectal swab c/s
• Ceftriaxone 1 gm iv q 12 hr
• Paracet prn for fever
• ORS prn

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Acute infectious diarrhea

• Perform initial assessment
• Dehydration
• Duration gt 1 day
• Inflammatory type
• - Fever
• - Blood in stool
• -Tenesmus

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Acute inflammatory diarrhea

• Bacteria most common
• Shigella
• Salmonella
• Aeromonas
• Plesiomonas shigelloides
• Vibrio parahemolyticus
• Campylobacter jejuni

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Acute inflammatory diarrhea

• Other cause
• Entameba histolytica
• Clostridium difficle toxin induced colitis
• Herpes simplex colitis
• Radiation proctitis
• Ischemic colitis
• Cancer

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Acute non-inflammatory diarrhea

• Bacteria cause
• Vibrio cholerae
• Enterotoxigenic E. coli (Traveller diarrhea)
• Toxin mediated Bacillus cereus
• Viral cause
• Norovirus, calcivirus

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Laboratory investigations

• Stool exam still need in Dx of inflammatory
  diarrhea

sens spec LR LR-
WBC gt5/HPF 0.50 0.83 2.94 0.60
Occult blood ve 0.44 0.72 1.57 0.78
Lactoferrin test 0.95 0.29 1.34 0.17
Gill et al. CID 200337
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Laboratory investigations

• Stool exam still need in Dx of inflammatory
  diarrhea

• Stool WBC
• Must examine with fresh specimen
• Sensitivity
• Swab specimen 44
• Cup specimen 95

Am J Trop Med Hyg 1979
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Laboratory investigations

• Stool WBC may be

ABSENT PRESENT VARIABLE
V. cholerae Enterotoxigenic E. coli Virus E. Histolytica Food poisoning Shigella Campylobacter Invasive E. coli Salmonella Non-cholera vibrio Yersinia C. difficile
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Laboratory investigation

• Not routinely indicated

• Low yield 1.5 -2.4
• Not useful in initial management
• More sensitive and specific in stool with WBC

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Treatment

• Dehydration nutrition
• Nonspecific symptomatic therapy
• Antimicrobial therapy

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Nonspecific symptomatic therapy

• Loperamide (Imodium)

• Inhibit intestinal peristalsis, antisecretory
• Not enter CNS non-addict

• May use with ATB in traveller s diarrhea
• May reduce duration of diarrhea 1 days

• Not use in bloody or inflammatory diarrhea

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Nonspecific symptomatic therapy

• Not effective

• Kaolin-Pectate
• Activated charcoal
• Anticholinergic
• Cholestyramine
• Lactobacilli

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common diarrheal pathogens isolated from rectal
swab culture 2004

Shigella 6
Salmonella nontyphoidal 22
Plesiomonas Shigelloides 2
Aeromonas hydrophila 3
Vibrio prahemolyticus 26
Vibrio cholerae 25
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Drug susceptibility of common diarrheal pathogens
in CDC region 6 Jan 04-Feb 05
Norfloxacin TMP-SMX
Shigella 98 4
Salmonella 100 80
Plesiomonas Shigelloides 100 ND
Aeromonas 96 100
Vibrio prahemolyticus 100 100
Vibrio cholerae 100 100
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Empirical Antimicrobial therapy

• Febrile community acquired diarrhea

• Norfloxacin 400 mg BID
• Ofloxacin 200 mg BID
• Levofloxacin 500 mg OD
• Ciprofloxacin 500 mg BID

• Duration 1-5 days

Thielman et al. N Engl J Med 200438-47
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Empirical Antimicrobial therapy

• Moderate to severe Travellers diarrhea

• Norfloxacin 400 mg BID
• Ofloxacin 200 mg BID
• Levofloxacin 500 mg OD
• Ciprofloxacin 500 mg BID

• Duration 1-5 days

Thielman et al. N Engl J Med 200438-47
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Empirical Antimicrobial therapy

• Severe nosocomial diarrhea -gt Antibiotic
  associated colitis

• Off any offending antibiotics
• Metronidazole 500 mg po TID or
• Vancomycin 125 mg QID

• Duration 10 days

Thielman et al. N Engl J Med 200438-47
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Specific antimicrobial therapy

• Non-typhoidal SALMONELLA (not group D)

• Antibiotic indicated if
• Severe
• Patient age lt 12 months or gt 50 years
• Underlying conditions Valvular heart, cancer,
  severe artherosclerosis, immunocompromised

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Specific antimicrobial therapy

• SHIGELLA

• Antibiotic indicated for 1-3 days
• Fluoroquinolones norfloxacin, ofloxacin
• Ceftriaxone iv

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Specific antimicrobial therapy

• VIBRIO CHOLERAE 01 or 0139

• Antibiotic indicated
• Doxycycline 300 mg once
• Tetracycline 500 mg QID x 3 days
• Ciprofloxacin 500 mg or norfloxacin 400 mg once

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Specific antimicrobial therapy

• CAMPYLOBACTER JEJUNI

• Consumption of undercooked poultry
• Antibiotic indicated if lt 4 days of symptoms
• Erythromycin 500 mg BID X 5 days
• Fluoroquinolones not use until sensitivity result
  known due to increase in resistance