ID12 Infectious Diseases Gastrointestinal Infections Toronto Notes 2016

Table 13. Bacteria in Infectious Diarrhea

Pathogen Source or Mode of Incubation Clinical Features Duration Antimicrobial Therapy Notes
Transmission
Fever Bloody Abdo N/V
Stool Pain
B. cereus – Type A Rice dishes 1-6 h – – – + <12 h None Preformed exotoxin
(emetic)
B. cereus – Type B Meats, vegetables, 8-16 h – – – – <24 h None Secondary endotoxin
(diarrheal) dried beans, cereals
Campylobacter jejuni Uncooked meat, 2-10 d + ± + ± <1 wk Macrolide or fluoroquinolone Most common bacterial
especially poultry if diarrhea >1 wk, cause of diarrhea in Canada
bloody diarrhea, or Associated with Guillain-
immunocompromised Barré syndrome
Clostridium difficile Can be normally Unclear ± ± ± – Variable Stop culprit antibiotic Usually follows
present in therapy, if possible antibiotic treatment
colon in small Supportive therapy (IV fluids) (especially clindamycin,
numbers (primary Mild-moderate disease: fluoroquinolones, penicillins,
risk factor for metronidazole PO x 10-14 d cephalosporins)
disease is exposure Severe disease: vancomycin Can develop
to antimicrobials) PO x 10 - 14 d pseudomembranous colitis
Toxic Megacolon:
metronidazole IV +
vancomycin PO (as above)
and general surgery consult
Clostridium perfringens Contaminated food, 8-12 h ± – + – <24 h None Clostridium spores are heat
especially meat and resistant
poultry Secondary enterotoxin
Enteroinvasive E. coli Contaminated 1-3 d + ± + – 7-10 d None Relatively uncommon
(EIEC) food/water
Enterotoxigenic E. coli Contaminated 1-3 d – – + – 3d Fluoroquinolone or Most common cause of
(ETEC) food/water azithromycin for moderate to traveller's diarrhea
severe symptoms Heat-labile and heat-stable
toxins
Enterohemorrhagic Contamination 3-8 d – + + ± 5-10 d None: antibiotics increase Shiga toxin production
E. coli (EHEC/STEC) of hamburger, raw risk of HUS Monitor renal function:
i.e. O157:H7 milk, drinking, and 10% develop HUS
recreational water Antidiarrheals increase risk
of HUS
Salmonella typhi Fecal-oral 10-14 d + ± + ± <5-7 d Empiric treatment with Salmonella typhi: "Rose
S. paratyphi Contaminated ceftriaxone or azithromycin spot" rash (on anterior
(i.e. Enteric Fever, food/water, travel Fluoroquinolone resistance thorax, upper abdomen),
Typhoid) to endemic area is increasing fever, and abdominal pain
precedes diarrhea
Non-typhoidal Contaminated 12-72 h + ± + + 3-7 d Ciprofloxacin only in severe
Salmonellosis animal food illness, extremes of age,
S. typhimurium, products, especially joint prostheses, valvular
S. enteritidis eggs, poultry, meat, heart disease, severe
milk atherosclerosis, cancer,
uremia
Shigella dysenteriae Fecal-oral 1-4 d + ± + + <1 wk Fluoroquinolone Very small inoculum needed
Contaminated for infection
food/water Complications include toxic
megacolon, HUS
Antidiarrheals may increase
risk of toxic megacolon
Staphylococcus Unrefrigerated meat 2-4 h – – + + 1-2 d None Heat-stable preformed
aureus and dairy products exotoxin
(custard, pudding,
potato salad, mayo)
Vibrio cholerae Contaminated 1-3 d – – – – 3-7 d Tetracycline or quinolones Massive watery diarrhea
food/water, (ciprofloxacin) (1-3 L/d)
especially shellfish Mortality <1% with
treatment
Yersinia Contaminated food 5d + ± + ± Up to Fluoroquinolone only for Majority of cases in children
Unpasteurized milk 3 wk severe illness 1-4 yr
Mesenteric adenitis and
terminal ileitis can occur
without diarrhea, mimicking
appendicitis
ID13 Infectious Diseases Gastrointestinal Infections Infectious Diseases ID13

Table 14. Parasites in Infectious Diarrhea

Pathogen Source or Mode of Incubation Clinical Features Duration Antimicrobial Therapy Notes
Transmission
Fever Bloody Abdo N/V
Stool Pain
Cryptosporidium Fecal-oral 7d ± – – + 1-20 d Paromomycin + nitazoxanide Immune reconstitution if
immunosuppressed
Entamoeba histolytica Worldwide 2-4 wk ± + – + Variable Metronidazole + If untreated, potential for
endemic areas iodoquinol or paromomycin liver abscess
Fecal-oral if symptomatic infection Sigmoidoscopy shows flat
Only iodoquinol or ulcers with yellow exudates
paromomycin for
asymptomatic cyst passage
Giardia lamblia Fecal-oral 1-4 wk – – + + Variable Metronidazole or Higher risk in: day care
Contaminated nitazoxanide children, intake of untreated
food/water Treatment of asymptomatic water ("beaver fever"), MSM,
carriers not recommended immunodeficiency
Toronto Notes 2016 (decreased IgA)
May need duodenal biopsy

Table 15. Viruses in Infectious Diarrhea

Pathogen Source or Mode of Incubation Clinical Features Duration Antimicrobial Therapy Notes
Transmission
Fever Bloody Abdo N/V
Stool Pain
Norovirus Fecal-oral 24 h – – + + 24 h None Noroviruses includes
Norwalk virus
Rotavirus Fecal-oral 2-4 d ± – – ± 3-8 d None Can cause severe
dehydration
Virtually all children are
infected by 3 yr of age
Oral vaccine given at 2 and
4 mo of age

Traveller's Diarrhea
• see Acute Diarrhea, ID10

Epidemiology
• most common illness to affect travellers
• up to 50% of travellers to developing countries affected in first 2 wk and 10-20% after returning
home

Etiology
• bacterial (80-90%): E. coli most common (ETEC), Campylobacter, Shigella, Salmonella, Vibrio
(non-cholera); wide regional variation (e.g. Campylobacter more common in Southeast Asia)
• viral: norovirus, rotavirus, and astrovirus account for 5-8%
• protozoal (rarely): Giardia, Entamoeba histolytica, Cryptosporidium, and Cyclospora for ~10% in
long-term travellers
• pathogen-negative traveller's diarrhea common despite exhaustive microbiological workup
Treatment
• rehydration is the mainstay of therapy
rehydrate with sealed beverages
in severe fluid loss use oral rehydration solutions (1 package in 1 L boiled or treated water)
• treat symptoms: antidiarrheal agents (e.g. bismuth salicylate, loperamide)
• empiric antibiotics in moderate or severe illness: ciprofloxacin or azithromycin or rifaximin
note: there is increasing fluoroquinolone resistance in causative agents, especially in
Southeast Asia

Prevention
• proper hygiene practices
avoid consumption of: foods or beverages from establishments with unhygienic conditions
(e.g. street vendors), raw fruits or vegetables without a peel, raw or undercooked meat and
seafood
avoid untreated water
• bismuth salicylate (Pepto-Bismol®): 60% effective (2 tablets qid according to CDC website)
• CDC Guidelines: antibiotic prophylaxis not recommended Bismuth salicylate (Pepto-Bismol®) can
increased risk of infection with resistant organisms cause patients to have black stools,
which may be mistaken for melena
high risk groups (e.g. immunocompromised) likely to be infected with pathogen not covered
by standard antimicrobial agents