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SOURCE

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Source: Roecker A, Bates B, Martin S. Gastrointestinal infections and enterotoxigenic poisonings. In: DiPiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=133893751. Accessed April 15, 2017.

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CONDITION/DISORDER SYNONYM

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  • Acute bacterial gastroenteritis.

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DEFINITION

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  • Decrease in consistency of bowel movements and increase in frequency of stools/day.

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ETIOLOGY

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  • Bacterial species most commonly associated with gastrointestinal (GI) infection and infectious diarrhea in the United States: Shigella, Salmonella Campylobacter, Yersinia, Escherichia, Clostridium, and Staphylococcus

  • Viral etiologies: rotaviruses, noroviruses, astrovirus, and enteric adenovirus.

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PATHOPHYSIOLOGY

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  • Enterotoxin production (Vibrio cholerae, Escherichia coli, Clostridium difficile)

    • Fluid secretion exceeds absorptive capacity of intestinal tract, resulting in watery diarrhea.

  • Invasion of colon by gram-negative bacteria (shigellosis, salmonellosis, campylobacteriosis)

  • Changes in transepithelial fluid balance and malabsorption (rotavirus, norovirus)

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EPIDEMIOLOGY

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  • Cholera: endemic in Ganges delta, West Bengal, Bangladesh, and southern Asia.

  • E. coli: common in the United States.

  • C. difficile: most common cause of infectious diarrhea in hospitalized patients in North America and Europe.

    • Associated with use of broad-spectrum antimicrobials.

  • Shigellosis primarily disease of children.

  • Salmonellosis primarily disease of infants, children, and adolescents.

  • Campylobacteriosis incidence peaks in children <1 year and those ages 15–44 years.

  • Rotavirus most common cause of diarrhea in infants and children ages 3–35 months.

  • Norovirus not well understood. Outbreaks documented in families, healthcare systems, college dormitories, and on cruise ships.

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PREVENTION

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  • Incidence of enteric infections decreased through:

    • Public health measures such as clean water supply and sanitation facilities, as well as quality control of commercial products.

    • Sanitary food handling and preparation practices.

    • Education concerning personal hygiene (eg, handwashing with soap and running water)

  • Vaccines.

    • Typhoid fever.

    • Rotavirus.

  • Traveler’s diarrhea.

    • Avoid fresh foods and water in developing countries.

    • Prophylaxis recommended in patients with:

      • Inflammatory bowel disease.

      • AIDS

      • Diabetes.

      • Heart disease in elderly.

      • Immunosuppressive medications.

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RISK FACTORS

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  • C. difficile: use of broad-spectrum antimicrobials.

    • Most commonly seen in elderly, debilitated patients, cancer patients, surgical patients, patients with nasogastric tubes, and those who frequently use laxatives.

  • Salmonellosis.

    • Decreased gastric acidity, use of antibiotics, malnutrition, and immunodeficiency states.

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CLINICAL PRESENTATION

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  • Inflammatory diarrhea presents as fever, tenesmus, or bloody stool, whereas secretory or watery diarrhea is more common and associated with more severe dehydration.

  • Cholera.

    • Incubation period 1–3 days.

    • Asymptomatic to life-threatening dehydration due to abrupt onset of watery diarrhea.

  • E. coli

    • Enterotoxigenic E. coli (ETEC)

      • Abrupt onset of nausea and watery stools, with or without abdominal cramping.

      • Resolves in 24–48 hours without complications.

    • Enteropathogenic E. coli (EPEC)

      • Acute onset of profuse watery diarrhea, vomiting, and low-grade fever.

    • Enteroadhesive E. coli (EAEC)

      • Persistent, watery, mucoid, secretory diarrhea with low-grade fever and little or ...

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