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Infectious colitis Infectious colitis Clerk: 方方方 Date: 2011/5/12

Infectious Colitis

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Page 1: Infectious Colitis

Infectious colitisInfectious colitis

Clerk: 方耀榮Date: 2011/5/12

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Infectious colitis refers to inflammation of the colon (the main part of the large intestine) due to infection by bacteria, viruses, parasites or fungi.

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Risk factor of infectious Risk factor of infectious colitiscolitisPoor hygiene Immune compromised (infancy,

advanced age, corticosteroid or immunosuppressive therapy, HIV infection).

Gastroenterol Clin North Am 2001;96:766.. Gastroenterol Clin North Am 2002;97:1769. Engl J Med 2002;346:334.

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Food HxFood Hx

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Food HxFood Hx

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Indications for diagnostic Indications for diagnostic evaluation evaluation 

**OB(+) & fecal leukocytes supports bact. Cause of diarrhea. (E coli O157:H7, salmonella, shigella, campylobacter, and E histolytica.)

**If hosp. >3d no Dx value., Test for C. difficile more helpful.

Fecal lactoferrin, sen. 90%, sp100%,Differ. Infl.m or Noninflm.diarr**Not widely avail.

Stool Cx, when??-Immunocompromised patients, HIV -Comorbidities that increase the risk for complications-Patients with more severe, inflammatory diarrhea (including bloody diarrhea)-Distinction between a flare of IBD and superimposed infection is critical-Some employees, such as food handlers, occasionally require negative stool cultures to return to work.

Routine Stool Cx-> identify Salmonella, Campylobacter, and shigella,

Ova or parasite studies, when??-Persistent diarrhea (giardia, E.histolytica, Crpytosporidium)-MSM or AIDS (Giardia, E histolytica, parasites for latter)-Community waterborne outbreak (Giardia, crypto.)-Bloody diarr. And few/ no leukocytes (Intestinal Amebiasis)

**3 specimens on consecutive days.

≥38.5ºC

•Special stool culture techniques are needed for yersinia, E coli O157:H7, vibrio, aeromonas, plesiomonas, and C difficile.

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Organisms..Organisms..• Child/adult without travel, afebrile, no gross blood or WBCs

in stool: – Rotavirus, caliciviruses (eg, Norwalk agent), E coli (GNR).

• Child/adult with fever, bloody stool or history of travel to subtropics/tropics (varies with epidemiology): – Campylobacter jejuni (GNR), E coli (GNR) (enterotoxigenic, enteroinvasive,

enteropathogenic, enteroaggregative, diarrhea-associated hemolytic and cytolethal distending toxin-producing, enterohemorrhagic O157:H7), shigella (GNR), salmonella (GNR), Yersinia enterocolitica (GNR), Clostridium difficile (GPR), aeromonas (GNR), plesiomonas (GNR), vibrio (GNR), cryptosporidium, Entamoeba histolytica, Giardia lamblia, cyclospora, strongyloides, edwardsiella (GNR), anaerobes, histoplasma (fungi) (in HIV infection).

• Febrile and non-bloody diarrhea.– Listeria monocytogene esp. pregnant women.

• Child/adult with vomiting and no fever: – S aureus (GPC), Bacillus cereus (GPR).

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ManagementManagement

Adequate fluid and electrolyte replacement and maintenance

Self-limitedAntibiotic therapy rarely required.

Empiric and specific antibiotic therapy can be considered in certain situations.

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Recommendations for the diagnosis and management of diarrheal illnesses.

Guerrant R L et al. Clin Infect Dis. 2001;32:331-351

© 2001 by the Infectious Diseases Society of America

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Empirical Abx GuidelinesEmpirical Abx Guidelines• Moderate to severe travelers' diarrhea

• >4 unformed stools daily, fever, blood, pus, or mucus in the stool.

• Those with >8 stools per day, volume depletion, symptoms for more than one week, those in whom hospitalization is being considered, and immunocompromised hosts.

• SSx of bacterial diarrhea such as fever, bloody diarrhea (except for suspected EHEC or C. difficile infection), and the presence of occult blood or fecal leukocytes in the stool.

EHEC HUS due to increase release of Shiga toxin after Abx admin.C.Difficile DC Abx and start Metronidazole or Vancomycin

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Fluoroquinolone for 3-5 days in the absence of suspected EHEC or fluoroquinolone-resistant campylobacter infection. (Grade 1A).

Azithromycin and erythromycin as alternative agents if fluoroquinolone resistance is suspected. (Grade 1B).

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ReferenceReferencePractice Guidelines for the Management of Infectious Diarrhea

Uptodate

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Thank you…Thank you…

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Specimens/ diagnostic Specimens/ diagnostic testtest• Stool for occult blood helpful in diagnosis of E coli O157:H7, salmonella,

shigella, campylobacter, and E histolytica.• Stool for culture and ova and parasites (3 specimens); the sensitivity of

culture is 72%, but its specificity is 100%.• Special stool culture techniques are needed for yersinia, E coli O157:H7,

vibrio, aeromonas, plesiomonas, and C difficile.• Stool cultures for salmonella, shigella, and campylobacter are not helpful

from patients who have been hospitalized for >3 days.• Specific examination for C difficile or its toxin is appropriate for patients

who have been hospitalized for >3 days. C difficile produces two toxins: Toxin A is an enterotoxin and toxin B is a cytotoxin. Rapid EIA test for both toxin A and B has 80–90% sensitivity for 1 stool specimen, >90% sensitivity for 2 stool specimens. C difficile tissue culture assay has a high sensitivity (94–100%) and specificity (99%) and is the definitive test, but its turn-around time is >48 hours.

• Immunodiagnosis of G lamblia, E histolytica, Cryptosporidium parvum cysts in stools is highly sensitive and specific.

• Proctosigmoidoscopy is indicated in patients with chronic or recurrent diarrhea or in diarrhea of unknown cause for smears of aspirates and biopsy. Culture of a biopsy specimen has a slightly higher sensitivity than routine stool culture.

• Obtain rectal and jejunal biopsies on HIV-infected patients, culture for bacterial pathogens and Mycobacteria (eg, MAC), and perform modified acid-fast stains for cryptosporidium, isospora, and cyclospora.

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Initial evaluationInitial evaluation• Careful history • Duration of symptoms (Acute,

persistent or chronic)• Frequency and characteristics

of the stool. • There should be an attempt to elicit

evidence of extracellular volume depletion (eg, decreased skin turgor, orthostatic hypotension).

• Fever and peritoneal signs may be clues to infection with an invasive enteric pathogen.

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Clinical features and physical and laboratory findings for common infectious diarrheal illnesses

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Historical cluesHistorical cluesFeversuggests infection with

invasive bacteriaFood HxTiming of symptomsAntibiotics useClostridium

difficileBloody diarrhea

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• within six hours suggest ingestion of a preformed toxin of Staphylococcus aureus or Bacillus cereus

• begin at 8 to 16 hours suggest infection with Clostridium perfringens

• at more than 16 hours can result from viral or bacterial infection (eg, contamination of food with enterotoxigenic or enterohemorrhagic E. coli).

• Syndromes that may begin with diarrhea but progress to fever and more systemic complaints such as head ache, muscle aches, stiff neck may suggest infection with Listeria monocytogenes, particularly in pregnant woman.

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Timing of symptomsTiming of symptoms

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