Causes of acute community-acquired diarrhoeal disease include pathogen infections such as bacteria: Yersinia enterica, Vibrio spp., Proxima Shiga-like bacteria; viruses: rotavirus, Novavirus (formerly Norwalker factor), enteroadenovirus, calicidavirus, astrovirus, microvirus, coronavirus; parasite: fecal sturangia. There are also non-infectious factors: side effects of the drug, irritable bowel syndrome, inflammatory bowel disease (ulcerative colitis or cloning disease), radiation ischemic bowel disease, incomplete intestinal obstruction, endocrine disorders, etc.
Clinical manifestations
History (symptoms): Severe bloody stools? Persistent, fever, tenesmus, symptoms of dehydration.
History (epidemiology): outbreak? Tourism, antibiotic use.
Traveler's diarrhea (developing countries): Enterototoxic E. coli (diagnosis/treatment empiric use of fluoroquinolones) is the main cause, others include novavirus, Salmonella, Shigella, Giardia, Yersinia.
Bloody stools: E. coli O157 (avoid the use of antibiotics), hemolytic E. coli, inflammatory bowel disease.
Antibiotic exposure: especially broad-spectrum β-lactam antibiotics, fluoroquinolones, or clindamycin. Clostridium difficile (20%), antibiotic-induced carbohydrate malabsorption. Community-acquired Clostridium difficile is defined as no history of antibiotic exposure and hospitalization.
Important historical data:
1. Severe symptoms: bleeding, fever, dehydration, vomiting;
2. Location: Recent travel to developing countries, E. coli, Salmonella, Shigella, Yersinia, O-bacterium, Norwalk factor;
3. Antibiotic-related: carbohydrate malabsorption 75%, Clostridium difficile 20%, Klebsiella acid-producing, Staphylococcus aureus, Bacterium during production;
4. Parasites: Giardia, histolytic amoeba, roundworm;
5. The most common bacteria: Salmonella, Yersinia, Shigella;
6. Hemorrhagic: hemolytic E. coli, E. coli O157;
7. Outbreaks: Nova virus, Salmonella;
8. Novavirus, adenovirus, microvirus, coronavirus, calicivirus;
9. Food poisoning outbreaks: Salmonella, Yersinia.
diagnosis
Stool leukocytes: suggests Yersinia, Clostridium difficile, Salmonella, Shigella.
Laboratory: Stool Cultures: Salmonella, Shigella, Yersinia ± E. coli O157:H7, Yersinia pestis, Vibrio cholerae (seasonal).
Laboratory (if there is a history of antibiotic exposure): Clostridium difficile toxin assay, toxin B or ELA (toxinSY A or A and B) or PCR (Clostridium difficile toxin gene).
Laboratory (parasite): histolytic amoeba standard O, P, commonly used specific AFB staining/trichromatic staining to identify coccidioides, round spore, giardia antigen (ELA).
treat
Sequential evaluation
1. Assessment: degree of diarrhea, duration, inflammatory symptoms (fever, bleeding, tenesmus after dysesmus).
2. Symptomatic treatment: hydration + loperamide (first dose 4 mg PO, followed by 2 mg per hour, maximum dose 16 mg/day)
3. Preventive treatment: travel, outbreaks, nosocomial infections, antibiotic exposure.
4. Stool test: travel-related (E. coli); outbreak (Salmonella, Nova virus); antibiotic exposure (Clostridium difficile); hemorrhagic (E. coli O157:H7, hemolytic amoeba).
Empiric antibiotic therapy (usually used in severe cases): ciprofloxacin 500 mg PO 2 times/day for х3 days. Travel-related: ciprofloxacin/levofloxacin for 1 to 3 days, if symptoms are > 7 days, minocycline 500 mg PO for 3 times/day for х7-10 days.
Reported cases: Salmonella, Shigella, E. coli O157:H7, Spsporidium, Giardia.
Pathogen-specific therapy (IDSACID2001;32:331).
Shigella: Ciprofloxacin 500 mg PO 2 times/day х3 days or levofloxacin 500 mg PO once/day for х3 days. Immunodeficient people are treated for 7 to 10 days.
Salmonella (antibiotic therapy: severe, age >50 years, valvular disease, severe atherosclerosis, tumors, AIDS, uremia): ciprofloxacin 500 mg PO, 2 times/day х 5-7 days, TMP-SMX PO, 2 times/day х 5-7 days, ceftriaxone 2 g IM/IV х 5-7 days. Immunocompromised people are treated for 14 days (recurrent cases).
Yersinia: erythromycin 500 mg PO, х 5 days 2 times/day (high rate of quinolone resistance).
Hemorrhagic Escherichia coli (Shiga-like toxin-blood stool): antibiotic therapy is not required, and antibiotic therapy can aggravate toxin release.
Clostridium difficile: antibiotic plus metronidazole 250 mg alternate day POх 10 days or PO vancomycin 125 mg orally every other day for х 10 days.
Giardia: metronidazole 250-750 mg PO х 7-10 days or 2 g tinidazole х1 orally 1 dose.
Roundworm: TMP-SMX 1 po, 2 times/day х 7-10 days. Immunocompromised populations: TMP-SMZ, 1 tablet, orally х 10 days every other day, followed by TMP-SMZ 3 times a week.
tissue-soluble amoeba: metronidazole 750 mg PO three times daily for х 5-10 days + paromycin 500 mg PO three times daily for 7 days. Alternative treatment: tinidazole 2 g PO for х3 days once daily, sequentially baronomycin, diiodoquinoline, dichlornit furoate.
Coccidioides: TMP-SMX, х 7-10 days orally 2 times/day. Immunocompromised populations: TMP-SMZ1 tablets or TMP-SMX1 tablets PO, 2 times/day or ofloxacin 300 mg PO, 2 times/day x 3 days.
Avoid milk, dairy products, coffee, fried foods, irritating foods.
Non-specific treatment
Rehydration: Mild diarrhea is given less residue soup and a small amount of juice to be fed in divided doses.
Food matches bowel movements: watery stools - soup, soup, yogurt, soft drinks, gels± salty biscuits; contains a small amount of feces - rice, bread, grilled fish, chicken, baked potatoes.
Avoid milk, dairy products, coffee, fried foods, irritating foods.
Avoid antibiotics: Escherichia coli O157:H7 (bloody stool) and Clostridium difficile.
Escherichia coli O157:H7 and Clostridium difficile infection consider lolopiperamide (OTC) 4 mg, followed by 2 mg to stool formation, with a maximum dose of 16 mg/day per day.
Follow
1. Outbreaks: If salmonella or Nova virus infection is suspected, it should be reported to the relevant health department.
2. Reports: Cholera, Salmonella, Shigella, E. coli O157:H7, Giardia.
Additional Information
Priority given: rehydration, treatment of shiga-like toxins (fluoroquinolones), antibiotics when avoiding bloody stools (E. coli O157:H7).
Infectious diarrhea (leukocytes in the stool, tenesmus, fever): consider Salmonella, Shigella, Yersinia, Clostridium difficile, Y. pestis. In severe cases or in bloody stools, stool cultures are reserved.
Most common: Nova virus, which can be sporadic or vacuous (hospitals, nurses' dormitories, cruise ships, etc.), water sports.
Outbreaks of food poisoning: Salmonella, E. coli O157, Novavirus, Y. pestis, Vibrio (seafood), Yersinia (poultry).
This article is excerpted from the ABX Guide