Gastrointestinal Infections

Dr. Salah Wageehuddein,

Clinical Pharmacy
 INTRODUCTION
• Most of GI infections caused by viruses, &
some are caused by bacteria or other
organisms.
• In underdeveloped and developing countries,
acute gastroenteritis involving diarrhea is the
leading cause of mortality in infants & children
younger than 5 years of age.

Dr. Salah Wageehuddein, Clinical Pharmacy

 REHYDRATION THERAPY
• Fluid replacement is the cornerstone of
therapy for diarrhea regardless of etiology.
• Weight loss is the most reliable means of
determining the extent of water loss.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Clinical signs:
• Changes in skin turgor
• Sunken eyes
• Dry mucous membranes
• Decreased tearing
• Decreased urine output
• Altered mentation
• Changes in V/S

Dr. Salah Wageehuddein, Clinical Pharmacy

• The necessary components of oral rehydration
therapy (ORT) solutions include glucose, Na+,
K+, Cl-, & H2O.
• Weight loss of 9-10% is considered severe and
requires IV fluid replacement with RL or 0.9%
NaCl.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Antibiotics are not essential in the treatment
of most mild diarrheas.

Dr. Salah Wageehuddein, Clinical Pharmacy

 Cholera (Vibrio cholerae)
• Mechanisms for transmission:
– Animal reservoirs.
– Chronic carriers.
– Asymptomatic or mild disease.
– Victims, or water reservoirs.
• Most pathology of cholera is thought to result
from an enterotoxin that ↑s cAMP–mediated
secretion of Cl- ion into the intestinal lumen,
which results in isotonic secretion (primarily in
the small intestine).
Dr. Salah Wageehuddein, Clinical Pharmacy
• The incubation period is 1-3 days.
• Characterized by a spectrum from the asymptomatic
state to the most severe typical cholera syndrome.
• Patients may lose up to 1 L of isotonic fluid every h.
• The onset of diarrhea is abrupt and is followed rapidly
or sometimes preceded by vomiting.
• Fever occurs in less than 5% of patients.
• In the most severe state, death may occur in 2-4 h if
not treated.

Dr. Salah Wageehuddein, Clinical Pharmacy

Treatment
• Fluid and electrolyte replacement with ORT to
restore fluid and electrolyte losses.
• Rice-based rehydration formulations are the
preferred ORT for cholera patients.
• In patients who cannot tolerate ORT, IV
therapy with RL can be used.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Antibiotics can be used
• Advantages:
– shorten the duration of diarrhea
– decrease the volume of fluid lost
– shorten the duration of the carrier state.
• 1st line: single dose of doxycycline po
(fluoroquinolones if resistance)
• In children younger than 7 years of age, co-
trimoxazole, erythromycin, & furazolidone can be
used.

Dr. Salah Wageehuddein, Clinical Pharmacy

Dr. Salah Wageehuddein, Clinical Pharmacy
 ESCHERICHIA COLI
• GI disease may be caused by:
– enterotoxigenic E. coli (ETEC) (traveler’s diarrhea)
– enteroinvasive E. coli
– enteropathogenic E. coli
– enteroadhesive E. coli
– enterohemorrhagic E. coli .

Dr. Salah Wageehuddein, Clinical Pharmacy

• ETEC is the most common toxins & diarrhea as
a result.
• Symptoms:
– Nausea
– Watery stools
– Abdominal cramping (+ve or –ve)
• Most diarrhea is typically abrupt in onset &
resolves within 24-48 hs without complication.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Most cases respond readily to ORT, & should
be initiated at the onset of diarrhea.
• Antibiotic therapy is seldom necessary.
• Prophylaxis effectively prevent the
development of ETEC diarrhea.
• Loperamide should not be used in patients
with fever or dysentery.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Prophylaxis:
– Doxycycline, or
– Co-trimoxazole, or
– Fluoroquinolone

* This approach is not routinely recommended.

Dr. Salah Wageehuddein, Clinical Pharmacy

 PSEUDOMEMBRANOUS COLITIS
(CLOSTRIDIUM DIFFICILE)
• Pseudomembranous colitis (PMC) results from
toxins produced by Clostridium difficile.
• It occurs most often in epidemic fashion and
affects highrisk groups such as the elderly,
debilitated patients, cancer patients, surgical
patients, any patient receiving antibiotics,
patients with nasogastric tubes, or those who
frequently use laxatives.
• PMC has been associated most often with broad-
spectrum antimicrobials, including clindamycin,
ampicillin, or third-generation cephalosporins.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Signs & symptoms:
– Severe abdominal pain
– Perfuse diarrhea
– High fever
– Marked leukocytosis.
• Symptoms can start a few days after the start
of antibiotic therapy to several weeks after
antibiotics have been stopped.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Diagnosis:
– Colonoscopic visualization of pseudomembranes
– Finding cytotoxins A or B in stools
– Stool culture for C. difficile.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Treatment:
• Discontinuation of the offending agent.
• Fluid and electrolyte replacement.
• 1st line antibacterial: metronidazole 250 mg po
qid.
• 2nd line: vancomycin, 125 mg po qid.
• 3rd line: Bacitracin.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Vancomycin used in case of:
– Patients not responding to metronidazole
– Organisms resistant to metronidazole
– Patients allergic or intolerant to metronidazole
– Patients who are pregnant or younger than 10
years
– Critically ill patients
– Diarrhea that is caused by Staphylococcus aureus.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Drugs that inhibit peristalsis, such as
diphenoxylate, are C/Ied.
• Relapse can occur & may be treated with
metronidazole or vancomycin for 10-14 days.

Dr. Salah Wageehuddein, Clinical Pharmacy

INVASIVE (DYSENTERY-LIKE) DIARRHEA
• BACILLARY DYSENTERY (SHIGELLOSIS)
• 4 species of Shigella are most often associated
with disease:
– S. dysenteriae type I
– S. flexneri
– S. boydii
– S. sonnei.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Causes:
– Poor sanitation
– Poor personal hygiene
– Inadequate water supply
– Malnutrition
• Transmission: fecal–oral.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Initial signs and symptoms:
– Abdominal pain
– Cramping
– Fever
• Then:
– Frequent watery stools.
• Then:
– Decrease in fever
– Severe abdominal pain
– Tenderness
• Then:
– Bloody diarrhea & dysentery.

Dr. Salah Wageehuddein, Clinical Pharmacy

• If untreated, bacillary dysentery usually lasts
about 1 week.
• Shigellosis is usually a self-limiting disease.
• Most patients recover in 4-7 days.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Treatment:
• Correction of fluid and electrolyte
disturbances.
• Antimicrobial use occasionally.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Antimicrobials are indicated for those who are
– immunocompromised
– children in daycare centers
– the elderly
– malnourished children
– healthcare workers.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Antimicrobials:
• Co-trimoxazole
• Ciprofloxacin, norfloxacin
• Fluoroquinolones are generally C/Ied in
children & adolescents.

Dr. Salah Wageehuddein, Clinical Pharmacy

 SALMONELLOSIS
• Four categories:
– Acute gastroenteritis (enterocolitis).
– Bacteremia.
– Extraintestinal localized infection.
– Enteric fever (typhoid and paratyphoid fever).
• S. typhimurium is the most common cause.
• It may affect infants, children, & adolescents.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Risk factors:
– Decrease gastric acidity
– Antibiotic use
– Malnutrition
– Immunodeficiency states.
• Contaminated food or water is implicated in
most cases.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Signs & symptoms:
• Nausea and vomiting within 72 hours of
ingestion.
• Then:
– Crampy abdominal pain
– Fever (typhoid fever)
– Diarrhea

Dr. Salah Wageehuddein, Clinical Pharmacy

• Diagnosis:
– Signs & symptoms
– Stool culture.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Extraluminal infection and/or abscess
formation can occur in bone, cysts, heart,
kidney, liver, lungs, pericardium, spleen, &
tumors.
• Enteric fever caused by S. typhi is called
typhoid fever & if caused by any other
serotype, it is referred to as paratyphoid fever.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Treatment
• Fluid and electrolyte replacement.
• Antimotility drugs should be avoided because
risk of mucosal invasion & complications.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Antibiotics have no effect on the duration of
fever or diarrhea, & use of them increases
resistance & duration of fecal shedding.
• Antibiotics should be used in neonates or
infants younger than 6 months, patients with
primary or secondary immunodeficiency,
severely symptomatic patients with fever &
bloody diarrhea.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Recommended antibiotics with adult doses
include:
– Fluoroquinolones
– Co-trimoxazole
– Ampicillin
– 3rd generation cephalosporins.

Dr. Salah Wageehuddein, Clinical Pharmacy

• Bacteremia:
• Combination of a third-generation cephalosporin
(ceftriaxone 2 g IV daily) and ciprofloxacin 500 mg
po bid.
• A short course of 3 to 5 days is effective but a
minimum of 10 days is recommended in severe
cases.
• The drug of choice for chronic carriers of
Salmonella is norfloxacin, 400 mg po bid for 28
days.
Dr. Salah Wageehuddein, Clinical Pharmacy