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Source: Martin S and Jung R. Gastrointestinal Infections and Enterotoxigenic Poisonings. In: DiPiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=8003383. Accessed June 25, 2012.

  • Acute bacterial gastroenteritis

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

  • Bacterial species most commonly associated with gastrointestinal (GI) infection and infectious diarrhea in the United States: Shigella, SalmonellaCampylobacter, Yersinia, Escherichia, Clostridium, and Staphylococcus.
  • Viral etiologies: rotaviruses, noroviruses, astrovirus, and enteric adenovirus

  • Enterotoxin production (Vibrio cholerae, E. 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)

  • Cholera: endemic in Ganges delta, West Bengal, Bangladesh, and southern Asia
  • Escherichia coli: common in United States
  • Clostridium 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.

  • 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 (e.g., 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

  • Clostridium 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

  • 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
  • Escherichia 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 no vomiting
    • Enteroinvasive E. coli (EIEC)
      • Watery diarrhea
      • May be indistinguishable from ETEC.
    • Enterohemorrhagic E. coli (EHEC)
      • Initial presentation: Cramping abdominal pain, abdominal distension, and watery diarrhea
      • Nausea (66%), vomiting (<50%), elevated white blood cell (WBC) count with left shift, afebrile
      • Progresses in 1–2 days to bloody diarrhea with increased abdominal pain (as many as 12 bloody stools/day).
      • Illness resolves in 1 week.
      • Hemolytic uremic syndrome (HUS) may develop in 2–7% of patients, particularly children <5 years and elderly.
  • Clostridium difficile
    • Onset of diarrhea during or after antimicrobial use
      • Can be delayed for 2–3 months
      • ...

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