Gastroenteritis 

Definition

Gastroenteritis is a catchall term for infection or irritation of the digestive tract, particularly the stomach
and intestine. It is frequently referred to as the stomach or intestinal flu, although the influenza virus is
not associated with this illness. Major symptoms include nausea and vomiting, diarrhea, and abdominal
cramps. These symptoms are sometimes also accompanied by fever and overall weakness. Gastroenteritis
typically lasts about three days. Adults usually recover without problem, but children, the elderly, and
anyone with an underlying disease are more vulnerable to complications such as dehydration.

Description

Gastroenteritis is an uncomfortable and inconvenient ailment, but it is rarely life-threatening in the United
States and other developed nations. However, an estimated 220,000 children younger than age five are
hospitalized with gastroenteritis symptoms in the United States annually. Of these children, 300 die as a
result of severe diarrhea and dehydration. In developing nations, diarrheal illnesses are a major source of
mortality. In 1990, approximately three million deaths occurred worldwide as a result of diarrheal illness.
The most common cause of gastroenteritis is viral infection. Viruses such as rotavirus, adenovirus,
astrovirus, and calicivirus and small round-structured viruses (SRSVs) are found all over the world.
Exposure typically occurs through the fecal-oral route, such as by consuming foods contaminated by fecal
material related to poor sanitation. However, the infective dose can be very low (approximately 100 virus
particles), so other routes of transmission are quite probable.
Typically, children are more vulnerable to rotaviruses, the most significant cause of acute watery
diarrhea. Annually, worldwide, rotaviruses are estimated to cause 800,000 deaths in children below age
five. For this reason, much research has gone into developing a vaccine to protect children from this
virus. Adults can be infected with rotaviruses, but these infections typically have minimal or no
symptoms.
Children are also susceptible to adenoviruses and astroviruses, which are minor causes of childhood
gastroenteritis. Adults experience illness from astroviruses as well, but the major causes of adult viral
gastroenteritis are the caliciviruses and SRSVs. These viruses also cause illness in children. The SRSVs
are a type of calicivirus and include the Norwalk, Southhampton, and Lonsdale viruses. These viruses are
the most likely to produce vomiting as a major symptom.
Bacterial gastroenteritis is frequently a result of poor sanitation, the lack of safe drinking water, or
contaminated food-conditions common in developing nations. Natural or man-made disasters can make
underlying problems in sanitation and food safety worse. In developed nations, the modern food
production system potentially exposes millions of people to disease-causing bacteria through its intensive
production and distribution methods. Common types of bacterial gastroenteritis can be linked to
Salmonella and Campylobacter bacteria; however, Escherichia coli 0157 and Listeria monocytogenes are
creating increased concern in developed nations. Cholera and Shigella remain two diseases of great
concern in developing countries, and research to develop long-term vaccines against them is underway.

Causes and symptoms

Gastroenteritis arises from ingestion of viruses, certain bacteria, or parasites. Food that has spoiled may
also cause illness. Certain medications and excessive alcohol can irritate the digestive tract to the point of
inducing gastroenteritis. Regardless of the cause, the symptoms of gastroenteritis include diarrhea, nausea
and vomiting, and abdominal pain and cramps. Sufferers may also experience bloating, low fever, and
overall tiredness. Typically, the symptoms last only two to three days, but some viruses may last up to a
week.
A usual bout of gastroenteritis shouldn't require a visit to the doctor. However, medical treatment is
essential if symptoms worsen or if there are complications. Infants, young children, the elderly, and
persons with underlying disease require special attention in this regard.
The greatest danger presented by gastroenteritis is dehydration. The loss of fluids through diarrhea and
vomiting can upset the body's electrolyte balance, leading to potentially life-threatening problems such as
heart beat abnormalities (arrhythmia). The risk of dehydration increases as symptoms are prolonged.
Dehydration should be suspected if a dry mouth, increased or excessive thirst, or scanty urination is
experienced.
If symptoms do not resolve within a week, an infection or disorder more serious than gastroenteritis may
be involved. Symptoms of great concern include a high fever (102 ° F [38.9 °C] or above), blood or
mucus in the diarrhea, blood in the vomit, and severe abdominal pain or swelling. These symptoms
require prompt medical attention.

Diagnosis

The symptoms of gastroenteritis are usually enough to identify the illness. Unless there is an outbreak
affecting several people or complications are encountered in a particular case, identifying the specific
cause of the illness is not a priority. However, if identification of the infectious agent is required, a stool
sample will be collected and analyzed for the presence of viruses, disease-causing (pathogenic) bacteria,
or parasites.

Treatment

Gastroenteritis is a self-limiting illness which will resolve by itself. However, for comfort and
convenience, a person may use over-the-counter medications such as Pepto Bismol to relieve the
symptoms. These medications work by altering the ability of the intestine to move or secrete
spontaneously, absorbing toxins and water, or altering intestinal microflora. Some over-the-counter
medicines use more than one element to treat symptoms.
If over-the-counter medications are ineffective and medical treatment is sought, a doctor may prescribe a
more powerful anti-diarrheal drug, such as motofen or lomotil. Should pathogenic bacteria or parasites be
identified in the patient's stool sample, medications such as antibiotics will be prescribed.
It is important to stay hydrated and nourished during a bout of gastroenteritis. If dehydration is absent, the
drinking of generous amounts of nonalcoholic fluids, such as water or juice, is adequate. Caffeine, since it
increases urine output, should be avoided. The traditional BRAT diet-bananas, rice, applesauce, and toast-
is tolerated by the tender gastrointestinal system, but it is not particularly nutritious. Many, but not all,
medical researchers recommend a diet that includes complex carbohydrates (e.g., rice, wheat, potatoes,
bread, and cereal), lean meats, yogurt, fruit, and vegetables. Milk and other dairy products shouldn't
create problems if they are part of the normal diet. Fatty foods or foods with a lot of sugar should be
avoided. These recommendations are based on clinical experience and controlled trials, but are not
universally accepted.
Minimal to moderate dehydration is treated with oral rehydrating solutions that contain glucose and
electrolytes. These solutions are commercially available under names such as Naturalyte, Pedialyte,
Infalyte, and Rehydralyte. Oral rehydrating solutions are formulated based on physiological properties.
Fluids that are not based on these properties-such as cola, apple juice, broth, and sports beverages-are not
recommended to treat dehydration. If vomiting interferes with oral rehydration, small frequent fluid
intake may be better tolerated. Should oral rehydration fail or severe dehydration occur, medical
treatment in the form of intravenous (IV) therapy is required. IV therapy can be followed with oral
rehydration as the patient's condition improves. Once normal hydration is achieved, the patient can return
to a regular diet.
Alternative treatment

Symptoms of uncomplicated gastroenteritis can be relieved with adjustments in diet, herbal remedies, and
homeopathy. An infusion of meadowsweet (Filipendula ulmaria) may be effective in reducing nausea
and stomach acidity. Once the worst symptoms are relieved, slippery elm (Ulmus fulva) can help calm the
digestive tract. Of the homeopathic remedies available, Arsenicum album, ipecac, or Nux vomica are three
said to relieve the symptoms of gastroenteritis.
Probiotics, bacteria that are beneficial to a person's health, are recommended during the recovery phase of
gastroenteritis. Specifically, live cultures of Lactobacillus acidophilus are said to be effective in soothing
the digestive tract and returning the intestinal flora to normal. L. acidophilus is found in live-culture
yogurt, as well as in capsule or powder form at health food stores. The use of probiotics is found in folk
remedies and has some support in the medical literature. Castor oil packs to the abdomen can reduce
inflammation and also reduce spasms or discomfort.

Prognosis

Gastroenteritis is usually resolved within two to three days and there are no long-term effects. If
dehydration occurs, recovery is extended by a few days.

Prevention

There are few steps that can be taken to avoid gastroenteritis. Ensuring that food is well-cooked and
unspoiled can prevent bacterial gastroenteritis, but may not be effective against viral gastroenteritis.

///

Acute gastroenteritis could be more simply called a long, and potentially lethal bout of stomach flu. The
most common symptoms are diarrhea, vomiting and stomach pain, because whatever causes the condition
inflames the gastrointestinal tract. Acute gastroenteritis is quite common among children, though it is
certainly possible for adults to suffer from it as well. While most cases of gastroenteritis last a few days,
acute gastroenteritis can last for weeks and months.

Numerous things may cause acute gastroenteritis. Bacterial infection is frequently a factor, and infection
by parasites like giardia can cause acute gastroenteritis to last for several weeks. Viruses can also cause
lengthy stomach flu, particularly rotaviruses and noroviruses. Accidental poisoning or exposure to toxins
may also instigate acute gastroenteritis as well.

When a person does not recover from stomach flu symptoms within a day or so, it is usually a good idea
to see a doctor. Some types of acute gastroenteritis will not resolve without antibiotic treatment,
especially when bacteria or exposure to parasites are the cause. Physicians may want to diagnose the
cause by analyzing a stool sample, when stomach symptoms remain problematic.

Another reason to seek medical treatment is that some forms of acute gastroenteritis mimic appendicitis,
which may require emergency treatment. As well, young children run an especially high risk of becoming
dehydrated during a long course of the stomach flu. One should receive directions regarding how to help
affected kids or adults get more fluids. Sometimes children, those with compromised immune systems,
and the elderly may require hospitalization and intravenous fluids. Dehydration can actually cause greater
nausea, and can begin to cause organ shut down if not properly addressed.

Even through causes for acute gastroenteritis vary, methods of transmission from one person to another
usually remain the same. Generally, contact with the fecal matter of a person with the condition and then
improperly washing or not washing the hands causes acute gastroenteritis to be quite contagious. Proper
handwashing for both the ill person, and well people in the family is always encouraged.

Other methods of transmission of acute gastroenteritis can include eating food or drinking liquids
contaminated with bacteria or parasites. For example, poorly cooked hamburger might result in a very
severe case of acute gastroenteritis due to exposure to E. coli, a sometimes lethal bacterial infection in
young children. Drinking improperly treated water, or drinking from streams and lakes can expose one to
giardia, which can leave one ill for many weeks, without treatment.

cute gastroenteritis remains a serious health issue, and is responsible for over 50,000 hospitalizations of
children in the US each year. In developing countries, acute gastroenteritis is the leading cause of death
for infants. Acute gastroenteritis should thus be taken seriously, and people should not hesitate to seek
medical treatment for especially seniors and children who have been ill for more than a day.

//

Gastroenteritis
From Wikipedia, the free encyclopedia

Jump to: navigation, search

Gastroenteritis

Classification and external resources

Gastroenteritis viruses: A = rotavirus, B = adenovirus, C =

Norovirus and D = Astrovirus. The virus particles are
shown at the same magnification to allow size comparison.

ICD-10 A02.0, A08., A09., J10.8, J11.8, K52.

ICD-9 009.0, 009.1, 558

DiseasesDB 30726

eMedicine emerg/213

MeSH D005759

Gastroenteritis (also known as gastric flu or stomach flu, although unrelated to influenza) is
inflammation of the gastrointestinal tract, involving both the stomach and the small intestine and resulting
in acute diarrhea. It can be transferred by contact with contaminated food and water. The inflammation is
caused most often by an infection from certain viruses or less often by bacteria, their toxins, parasites, or
an adverse reaction to something in the diet or medication. Current death rates have come down
significantly to approximately 1.5 million deaths annually in the year 2000, largely due to the global
introduction of oral rehydration therapy[1] and is a leading cause of death among infants and children
under 5.[2]

At least 50% of cases of gastroenteritis due to foodborne illness are caused by norovirus.[3] Another 20%
of cases, and the majority of severe cases in children, are due to rotavirus. Other significant viral agents
include adenovirus[4] and astrovirus.

Different species of bacteria can cause gastroenteritis, including Salmonella, Shigella, Staphylococcus,
Campylobacter jejuni, Clostridium, Escherichia coli, Yersinia, Vibrio cholerae, and others. Some sources
of the infection are improperly prepared food, reheated meat dishes, seafood, dairy, and bakery products.
Each organism causes slightly different symptoms but all result in diarrhea. Colitis, inflammation of the
large intestine, may also be present.

Risk factors include consumption of improperly prepared foods or contaminated water and travel or
residence in areas of poor sanitation. It is also common for river swimmers to become infected during
times of rain as a result of contaminated runoff water.[5]

Contents
[show]

[edit] Classification

Infectious gastroenteritis is caused by a wide variety of bacteria and viruses.

It is important to consider infectious gastroenteritis as a diagnosis per exclusionem. A few loose stools
and vomiting may be the result of systemic infection such as pneumonia, septicemia, urinary tract
infection and even meningitis. Surgical conditions such as appendicitis, intussusception and, rarely, even
Hirschsprung's disease may mislead the clinician. Endocrine disorders (e.g. thyrotoxicosis and Addison's
disease) are disorders that can cause diarrhea. Also, pancreatic insufficiency, short bowel syndrome,
Whipple's disease, coeliac disease, and laxative abuse should be excluded as possibilities.[6]

[edit] Bacterial gastroenteritis

For a list of bacteria causing gastroenteritis, see above. Pseudomembranous colitis is an important cause
of diarrhea in patients often recently treated with antibiotics.

If gastroenteritis in a child is severe enough to require admission to a hospital, then it is important to

distinguish between bacterial and viral infections. Bacteria, Shigella and Campylobacter, for example,
and parasites like Giardia can be treated with antibiotics

Traveler's diarrhea is usually a type of bacterial gastroenteritis.

[edit] Viral gastroenteritis

Viruses causing gastroenteritis include rotavirus, norovirus, adenovirus and astrovirus. Viruses do not
respond to antibiotics and infected children usually make a full recovery after a few days.[7] Children
admitted to hospital with gastroenteritis routinely are tested for rotavirus A to gather surveillance data
relevant to the epidemiological effects of rotavirus vaccination programs.[8][9] These children are routinely
tested also for norovirus, which is extraordinarily infectious and requires special isolation procedures to
avoid transmission to other patients. Other methods, electron microscopy and polyacrylamide gel
electrophoresis, are used in research laboratories.[10][11]

[edit] Symptoms and signs

Gastroenteritis often involves stomach pain or spasms, diarrhea and/or vomiting, with noninflammatory
infection of the upper small bowel, or inflammatory infections of the colon.[12][6][13][14]

The condition is usually of acute onset, normally lasting 1–6 days, and is self-limiting.

 Nausea and vomiting

 Diarrhea
 Loss of appetite
 Fever
 Headaches
 Abnormal flatulence
 Abdominal pain
 Abdominal cramps
 Bloody stools (dysentery - suggesting infection by amoeba, Campylobacter, Salmonella, Shigella
or some pathogenic strains of Escherichia coli[4])
 Fainting and Weakness
 Heartburn

The main contributing factors include poor feeding in infants. Diarrhea is common, and may be followed
by vomiting. Viral diarrhea usually causes frequent watery stools, whereas blood stained diarrhea may be
indicative of bacterial colitis. In some cases, even when the stomach is empty, bile can be vomited up.
A child with gastroenteritis may be lethargic, suffer lack of sleep, run a low fever, have signs of
dehydration (which include dry mucous membranes), tachycardia, reduced skin turgor, skin color
discoloration, sunken fontanelles, sunken eyeballs, darkened eye circles, glassy eyes, poor perfusion and
ultimately shock.

[edit] Diagnosis

Gastroenteritis is diagnosed based on symptoms, a complete medical history and a physical examination.
An accurate medical history may provide valuable information on the existence or inexistence of similar
symptoms in other members of the patient's family or friends. The duration, frequency, and description of
the patient's bowel movements and if they experience vomiting are also relevant and these question are
usually asked by a physician during the examination. [15]

No specific diagnostic tests are required in most patients with simple gastroenteritis. If symptoms
including fever, bloody stool and diarrhea persist for two weeks or more, examination of stool for
Clostridium difficile may be advisable along with cultures for bacteria including Salmonella, Shigella,
Campylobacter and Enterotoxic Escherichia coli. Microscopy for parasites, ova and cysts may also be
helpful.[citation needed]

A complete medical history may be helpful in diagnosing gastroenteritis. A complete and accurate
medical history of the patient includes information on travel history, exposure to poisons or other irritants,
diet change, food preparation habits or storage and medications. Patients who travel may be exposed to E.
Coli infections or parasite infections contacted from beverages or food. Swimming in contaminated water
or drinking from suspicious fresh water such as mountain streams or wells may indicate infection from
Giardia - an organism found in water that causes diarrhea.

Food poisoning must be considered in cases when the patient was exposed to undercooked or improperly
stored food. Depending on the type of bacteria that is causing the condition, the reactions appear in 2 to
72 hours. Detecting the specific infectious agent is required in order to establish a proper diagnosis and an
effective treatment plan.

The doctor may want to find whether the patient has been using broad-spectrum or multiple antibiotics in
their recent past. If so, they could be the cause of an irritation of the gastrointestinal tract.

During the physical examination, the doctor will look for other possible causes of the infection.
Conditions such as appendicitis, gallbladder disease, pancreatitis or diverticulitis may cause similar
symptoms but a physical examination will reveal a specific tenderness in the abdomen which is not
present in gastroenteritis.

Diagnosing gastroenteritis is mainly an exclusion procedure. Therefore in rare cases when the symptoms
are not enough to diagnose gastroenteritis, several tests may be performed in order to rule out other
gastrointestinal disorders. These include rectal examinations, complete blood count, electrolytes and
kidney function tests. However, when the symptoms are conclusive, no tests apart from the stool tests are
required to correctly diagnose gastroenteritis especially if the patient has traveled to at-risk areas.
[edit] Prevention

Percentage of rotavirus tests with positive results, by surveillance week, United States, July 2000--June
2009.

A rotavirus vaccine has between 2000 and 2009 decreased the number of cases of diarrhea due to
rotavirus in the United States.[16]

Gastroenteritis may be prevented through immunization. [17] The U.S. Food and Drug Administration
approved in 2006 a rotavirus called Rotateq that may be given to infants aged 6 to 32 weeks to prevent
getting infected with viral gastroenteritis. [18] The vaccines may however have side effects that are similar
to the mild flu symptoms.

Different types of vaccinations are available for Salmonella typhi and Vibrio cholera and which may be
administered to people who intend traveling in at-risk areas. However, the vaccines that are currently
available are effective only on rotavirual gastroenteritis.

Doctors recommend that food be properly cooked and stored to prevent gastroenteritis. Avoid suspect
food or drink. Thoroughly wash both hands before eating and after using the bathroom or changing
diapers. Viral gastroenteritis is a highly contagious disease and thus avoiding crowded spaces such as
markets, theaters or shopping centers may also help in preventing infection for those who have weak
resistance. Bleaching soiled laundry and household surfaces may help prevent spreading bacteria. [19]

[edit] Management

Gastroenteritis is usually an acute and self-limited disease that does not require pharmacological therapy.
[20]
The objective of treatment is to replace lost fluids and electrolytes. Oral rehydration is the preferred
method of replacing these losses in children with mild to moderate dehydration.[21] Metoclopramide and
ondansetron however may be helpful in children.[22]

[edit] Rehydration

The primary treatment of gastroenteritis in both children and adults is rehydration, i.e., replenishment of
water and electrolytes lost in the stools. This is preferably achieved by giving the person oral rehydration
therapy (ORT) although intravenous delivery may be required if a decreased level of consciousness or an
ileus is present.[23][24] Complex-carbohydrate-based Oral Rehydration Salts (ORS) such as those made
from wheat or rice have been found to be superior to simple sugar-based ORS.[25]

Sugary drinks such as soft drinks and fruit juice are not recommended for gastroenteritis in children under
5 years of age as they may make the diarrhea worse.[20] Plain water may be used if specific ORS are
unavailable or not palatable.[20]
[edit] Diet

It is recommended that breastfed infants continue to be nursed on demand and that formula-fed infants
should continue their usual formula immediately after rehydration with oral rehydration solutions.
Lactose-free or lactose-reduced formulas usually are not necessary.[26] Children receiving semisolid or
solid foods should continue to receive their usual diet during episodes of diarrhea. Foods high in simple
sugars should be avoided because the osmotic load might worsen diarrhea; therefore substantial amounts
of soft drinks, juice, and other high simple sugar foods should be avoided.[26] The practice of withholding
food is not recommended and immediate normal feeding is encouraged.[27] The BRAT diet (bananas, rice,
applesauce, toast and tea) is no longer recommended, as it contains insufficient nutrients and has no
benefit over normal feeding.[28]

[edit] Medications

Antiemetics

Antiemetic drugs may be helpful for vomiting in children. Ondansetron has some utility with a single
dose associated with less need for intravenous fluids, fewer hospitalizations, and decreased vomiting.[29][30]
[31]
Metoclopramide also might be helpful.[32] However there was an increased number of children who
returned and were subsequently admitted in those treated with ondansetron.[33] The intravenous
preparation of ondansetron may be given orally.[34]

Antibiotics

Antibiotics are not usually used for gastroenteritis, although they are sometimes used if symptoms are
severe (such as dysentry)[35] or a susceptible bacterial cause is isolated or suspected.[36] If antibiotics are
decided on, a fluoroquinolone or macrolide is often used.[13]

Pseudomembranous colitis, usually caused by antibiotics use, is managed by discontinuing the causative
agent and treating with either metronidazole or vancomycin.[13][14]

Antimotility agents

Antimotility drugs have a theoretical risk of causing complications; clinical experience, however, has
shown this to be unlikely.[6][13] They are thus discouraged in people with bloody diarrhea or diarrhea
complicated by a fever.[12]

Loperamide, an opioid analogue, is commonly used for the symptomatic treatment of diarrhea.[13]
Loperamide is not recommended in children as it may cross the immature blood brain barrier and cause
toxicity.

Bismuth subsalicylate (BSS), an insoluble complex of trivalent bismuth and salicylate, can be used in
mild-moderate cases.[6][13]

[edit] Alternative medicine

Probiotics
Some probiotics have been shown to be beneficial in preventing and treating various forms of
gastroenteritis.[28] Fermented milk products (such as yogurt) also reduce the duration of symptoms.[37]

Zinc

The World Health Organization recommends that infants and children receive a dietary supplement of
zinc for up to two weeks after onset of gastroenteritis.[38] A 2009 trial however did not find any benefit
from supplementation.[39]

[edit] Complications

Dehydration is a common complication of diarrhea. It can be made worse with the withholding fluids or
the administration of juice / soft drinks.[40] Malabsorption of lactose, the principal sugar in milk, may
occur. Though it may increase the diarrhea,[41] however, mothers should continue breastfeeding.

Metoclopramide Hydrochloride Oral tablet

What is this medicine?

METOCLOPRAMIDE (met oh kloe PRA mide) is used to treat the symptoms of gastroesophageal reflux
disease (GERD) like heartburn. It is also used to treat people with slow emptying of the stomach and
intestinal tract.

This medicine may be used for other purposes; ask your health care provider or pharmacist if you have
questions.

Metoclopramide (INN) (pronounced /ˌmɛtəˈklɒprəmaɪd/) is an antiemetic and gastroprokinetic agent.

Thus it is primarily used to treat nausea and vomiting, and to facilitate gastric emptying in patients with
gastroparesis. It is also a primary treatment for migraine headaches.

It is available under various trade names including Maxolon (Shire/Valeant), Reglan (Schwarz Pharma),
Degan (Lek), Maxeran (Sanofi Aventis), Primperan (Sanofi Aventis), Pylomid (Bosnalijek), Cerucal
(AWD Pharma), and Pramin (Generic).

Recently published analyses suggest that metoclopramide is the most common cause of drug-induced
movement disorders. Another analysis of study data by the FDA showed that about 20 percent of patients
in that study who used metoclopramide took it for longer than three months.[1] The FDA only approves
metoclopramide for 4-12 week short term treatment.
Mechanism of action

Metoclopramide was first described by Dr. Louis Justin-Besançon and C. Laville in 1964.[2] It appears to
bind to dopamine D2 receptors where it is a receptor antagonist, and is also a mixed 5-HT3 receptor
antagonist/5-HT4 receptor agonist.

The anti-emetic action of metoclopramide is due to its antagonist activity at D2 receptors in the
chemoreceptor trigger zone (CTZ) in the central nervous system (CNS)—this action prevents nausea and
vomiting triggered by most stimuli.[3] At higher doses, 5-HT3 antagonist activity may also contribute to
the anti-emetic effect.

The prokinetic activity of metoclopramide is mediated by muscarinic activity, D2 receptor antagonist

activity and 5-HT4 receptor agonist activity.[4][5] The prokinetic effect itself may also contribute to the anti-
emetic effect.

How should I use this medicine?

Take this medicine by mouth with a glass of water. Follow the directions on the prescription label. Take
this medicine on an empty stomach, about 30 minutes before eating. Take your doses at regular intervals.
Do not take your medicine more often than directed. Do not stop taking except on the advice of your
doctor or health care professional.

A special MedGuide will be given to you by the pharmacist with each prescription and refill. Be sure to
read this information carefully each time.
Talk to your pediatrician regarding the use of this medicine in children. Special care may be needed.

Overdosage: If you think you have taken too much of this medicine contact a poison control center or
emergency room at once.
NOTE: This medicine is only for you. Do not share this medicine with others.

What if I miss a dose?

If you miss a dose, take it as soon as you can. If it is almost time for your next dose, take only that dose.
Do not take double or extra doses.

What may interact with this medicine?

 acetaminophen
 cyclosporine
 digoxin
 medicines for blood pressure
 medicines for diabetes, including insulin
 medicines for hay fever and other allergies
 medicines for depression, especially an Monoamine Oxidase Inhibitor (MAOI)
 medicines for Parkinson's disease, like levodopa
 medicines for sleep or for pain
 tetracycline
This list may not describe all possible interactions. Give your health care provider a list of all the
medicines, herbs, non-prescription drugs, or dietary supplements you use. Also tell them if you smoke,
drink alcohol, or use illegal drugs. Some items may interact with your medicine.

What should I watch for while using this medicine?

It may take a few weeks for your stomach condition to start to get better. However, do not take this
medicine for longer than 12 weeks. The longer you take this medicine, and the more you take it, the
greater your chances are of developing serious side effects. If you are an elderly patient, a female patient,
or you have diabetes, you may be at an increased risk for side effects from this medicine. Contact your
doctor immediately if you start having movements you cannot control such as lip smacking, rapid
movements of the tongue, involuntary or uncontrollable movements of the eyes, head, arms and legs, or
muscle twitches and spasms.

Patients and their families should watch out for worsening depression or thoughts of suicide. Also watch
out for any sudden or severe changes in feelings such as feeling anxious, agitated, panicky, irritable,
hostile, aggressive, impulsive, severely restless, overly excited and hyperactive, or not being able to sleep.
If this happens, especially at the beginning of treatment or after a change in dose, call your doctor.

Do not treat yourself for high fever. Ask your doctor or health care professional for advice.

You may get drowsy or dizzy. Do not drive, use machinery, or do anything that needs mental alertness
until you know how this drug affects you. Do not stand or sit up quickly, especially if you are an older
patient. This reduces the risk of dizzy or fainting spells. Alcohol can make you more drowsy and dizzy.
Avoid alcoholic drinks.

What side effects may I notice from receiving this medicine?

Side effects that you should report to your doctor or health care professional as soon as possible:

 allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
 abnormal production of milk in females
 breast enlargement in both males and females
 change in the way you walk
 difficulty moving, speaking or swallowing
 drooling, lip smacking, or rapid movements of the tongue
 excessive sweating
 fever
 involuntary or uncontrollable movements of the eyes, head, arms and legs
 irregular heartbeat or palpitations
 muscle twitches and spasms
 unusually weak or tired

Side effects that usually do not require medical attention (report to your doctor or health care professional
if they continue or are bothersome):

 change in sex drive or performance

  depressed mood
 diarrhea
 difficulty sleeping
 headache
 menstrual changes
 restless or nervous

This list may not describe all possible side effects. Call your doctor for medical advice about side effects.
You may report side effects to FDA at 1-800-FDA-1088.

Where should I keep my medicine?

Keep out of the reach of children.

Store at room temperature between 20 and 25 degrees C (68 and 77 degrees F). Protect from light. Keep
container tightly closed. Throw away any unused medicine after the expiration date.

NOTE:This sheet is a summary. It may not cover all possible information. If you have questions about
this medicine, talk to your doctor, pharmacist, or health care provider.

Remember, keep this and all other medicines out of the reach of children, never share your medicines
with others, and use this medication only for the indication prescribed.

//

Ciprofloxacin Hydrochloride Oral tablet

what is this medicine?

CIPROFLOXACIN (sip roe FLOX a sin) is a quinolone antibiotic. It is used to treat certain kinds of
bacterial infections. It will not work for colds, flu, or other viral infections.

This medicine may be used for other purposes; ask your health care provider or pharmacist if you have
questions.

How should I use this medicine?

Take this medicine by mouth with a glass of water. Follow the directions on the prescription label. Take
your medicine at regular intervals. Do not take your medicine more often than directed. Take all of your
medicine as directed even if you think your are better. Do not skip doses or stop your medicine early.

You can take this medicine with food or on an empty stomach. It can be taken with a meal that contains
dairy or calcium, but do not take it alone with a dairy product, like milk or yogurt or calcium-fortified
juice.
A special MedGuide will be given to you by the pharmacist with each prescription and refill. Be sure to
read this information carefully each time.

Talk to your pediatrician regarding the use of this medicine in children. Special care may be needed.

Overdosage: If you think you have taken too much of this medicine contact a poison control center or
emergency room at once.
NOTE: This medicine is only for you. Do not share this medicine with others.

What if I miss a dose?

If you miss a dose, take it as soon as you can. If it is almost time for your next dose, take only that dose.
Do not take double or extra doses.

What may interact with this medicine?

Do not take this medicine with any of the following medications:

 cisapride
 droperidol
 terfenadine
 tizanidine

This medicine may also interact with the following medications:

 antacids
 caffeine
 cyclosporin
 didanosine (ddI) buffered tablets or powder
 medicines for diabetes
 medicines for inflammation like ibuprofen, naproxen
 methotrexate
 multivitamins
 omeprazole
 phenytoin
 probenecid
 sucralfate
 theophylline
 warfarin

This list may not describe all possible interactions. Give your health care provider a list of all the
medicines, herbs, non-prescription drugs, or dietary supplements you use. Also tell them if you smoke,
drink alcohol, or use illegal drugs. Some items may interact with your medicine.

What should I watch for while using this medicine?

Tell your doctor or health care professional if your symptoms do not improve.

Do not treat diarrhea with over the counter products. Contact your doctor if you have diarrhea that lasts
more than 2 days or if it is severe and watery.
You may get drowsy or dizzy. Do not drive, use machinery, or do anything that needs mental alertness
until you know how this medicine affects you. Do not stand or sit up quickly, especially if you are an
older patient. This reduces the risk of dizzy or fainting spells.

This medicine can make you more sensitive to the sun. Keep out of the sun. If you cannot avoid being in
the sun, wear protective clothing and use sunscreen. Do not use sun lamps or tanning beds/booths.

Avoid antacids, aluminum, calcium, iron, magnesium, and zinc products for 6 hours before and 2 hours
after taking a dose of this medicine.

What side effects may I notice from receiving this medicine?

Side effects that you should report to your doctor or health care professional as soon as possible:

 allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
 breathing problems
 confusion, nightmares or hallucinations
 feeling faint or lightheaded, falls
 irregular heartbeat
 joint, muscle or tendon pain or swelling
 pain or trouble passing urine
 redness, blistering, peeling or loosening of the skin, including inside the mouth
 seizure
 unusual pain, numbness, tingling, or weakness

Side effects that usually do not require medical attention (report to your doctor or health care professional
if they continue or are bothersome):

 diarrhea
 nausea or stomach upset
 white patches or sores in the mouth

This list may not describe all possible side effects. Call your doctor for medical advice about side effects.
You may report side effects to FDA at 1-800-FDA-1088.

Where should I keep my medicine?

Keep out of the reach of children.

Store at room temperature below 30 degrees C (86 degrees F). Keep container tightly closed. Throw away
any unused medicine after the expiration date.

NOTE:This sheet is a summary. It may not cover all possible information. If you have questions about
this medicine, talk to your doctor, pharmacist, or health care provider.

Remember, keep this and all other medicines out of the reach of children, never share your medicines
with others, and use this medication only for the indication prescribed.