Infective diarrhoea

What does self limiting mean?

doesn’t need any medical treatment to fix

What are the common causes of infective diarrhoea?

mainly viral - norovirus, some bacterial - campylobacter, salmonella, shigella, E.coli, rare protozoa - giardia

What are some of the thngs to consder if someone has diarrhoea caused by bacteria, or if you are trying to work out if they do?

history of travel, more serious side effects, may need to report to public health as caused by unsanitary conditions or infected food

What causes of diarrhoea should you report (that we learn about)?

urgently report - cholera, enteric fever, infectious bloody diarrhoea, urgent if part of cluster or outbreak - food poisoning 

What is diarrhoea defined as?

3 bowel movements in 24 hours

What are the 3 catagories of diarrhoea?

acute - less than 2 weeks, persistant - more than 2 weeks, less than 30 days, chronic - more than 30 days

What are the other symptoms associated with diarrhoea?

abdominal disconfort, nausea, and vomiting

What are some of the complications associated with diarrhoea?

dehydration, malnutrition, GI perforation, sepsis, death 

How do you detect dehydration?

using a skin pinch - pinch the skin for 2 seconds and time how long it takes the colouring to go back to normal, this is because of reduced skin turgor, they will also have cold extremities and pale skin (eyelids), altered mental state, hypotention, dryness of mucous membrane, decreased urine output, increased pulse, delayed capillary refill time

What groups do you need to be worried about with dehydration?

people on other meds, children, older adults, last two it can effect conciouness

Describe watery diarrhoea?

less common to have fever, no blood or mucus, mostly viral, mostly self-limiting, worry about dehydration

Describe bloody diarrhoea

dysentery, bacterial or parasitic, contains blood or mucus, high fever, nausea and vomitting, risk to those >50 years old of dehydration or malnutrition, need to report 

What does a fever with diarrhoea sometimes indicate?

bacteria got into blood stream, caused sepsis, other symptoms - dizzyness, low concentration and confusion, every hour delay increases mortality 

What should you be worried about with taking diarrhoetics and hart faliure?

loose lots of potassium, this can sometimes cause an arthmia and death

What should you suggest people with diarrhoea take? (always)

fluids with electrolytes either juice or water with electrolytes dissolved in them

What are the red flags for infective diarrhoea?

blood in stool, recent hospital treatment or antibiotic treatment, weight loss (with chronic), dehyration, sexual history (to exclude sexually transmitted enterc infection)

For what reasons would you send a stool sample to the lab?

systemically unwell, needs hospital admission or antibiotics, blood or pus in stool, immunocomprimised patient, recetley taken antibiotics a PPI or been in hospital - c.difficile, after foreign travel (parisites), 2 weeks or more, need to exclude infectious diarrhoea

Why do you have to send off a stool sample for an immunocompromised person?

easier for bacteria to grow, patient is more vunrable so the right antibiotic is very important

Why do you have to send off a stool sample for someone on a PPI (or recently)?

supresses acidity making it easier for bacteria to grow 

What is the management plan for oral rehydration solution?

first line is 1 or 2 sachets after every loose motion (sachet dissolved in 200mL of water), make up immediatley before use - can be stored for up to 24h in fridge (small children) 1h at room temp, dioralyte should only be reconsituted with water, check other compatabilty
IV if vomiting or calapse - aggressive cases only

What is the management plan for loperamide?

only take if afebrile, no blood, not systemically unwell, initially 4mg then 2mg after each loose stool, 6-8mg per dose, max 16mg per day, for 5 days max, 12+

How does loperamide work?

slows down interstinal movement so less frequent bowel movement, acts on the opoid receptor, doesn’t cross the blood brain barrier so not addictive 

Do you always need to give antibiotics?

no, mainly viral

What patient councelling do you provide?

wash hands thoroughly with soap and warm water after going to the toilet and before eating and preparing food, clean the toilet including the handle and seat with disinfectant after each episode, avoid sharing towels, flannels, cutlery, or utensils with other household members, avoid potentially unsafe tap water and undercooked food when abroad, fluids, reassurance, safety netting

What are the prescribing considerations for treating serious infective diarrhoea?

reveiw existing antibiotics and stop unless essential or switch to other antibiotic which is less risky, reveiw PPIs and other medicines with gastrointestinal activity or adverse affects, do not offer antimotility medicines as it can trap any bacteria 

What is the most risky antibiotic to cause c.diff infections?

beta lactams

What antibiotic do you give to an 18+ with a c.diff infection?

first line: oral vancomycin for 10 days 
second line: oral fidaxomicin for 10 days - for resistant cases 

Vancomycin is hydrophillic, why can you still give it orally?

it won’t diffuse out of the intestine but it doesn’t matter as only local treatment needed

What are the monitoring conditions for vancomycin?

serial tests of auditory function is helpful to minimise ototoxicity in patients with underlying hearing loss or who are receving concomitant therpary with other ototoxic drugs with prolonged use, recomended monitoring serum-vancomycin concentration in inflammatory interstinal disorders, nephron toxicity

What are the things you need to consider when prescribing vancomycin?

narrow therappeutic index medication - aggressively adverse effects, not given orallyfor systemic infections as not absorbed significantly, toxicity effects have higher chance in IV