Diarrhea- Madras

Is diarrhea a symptom or disorder?

symptom

What type of diarrhea can we self-treat?

a. acute (<14 days)

b. persistent (14 days- 4 weeks)

c. chronic (>4 weeks)

a (b-c refer to PCP)

For 90% of cases of acute diarrhea, you should not use _____________ since most are caused by a __________.

a. fluids, bacteria

b. antibiotics, virus

c. antibiotics, parasite

d. fluids, virus

b

What are some medications that can cause diarrhea?

• Mg antacids

• Metformin

• PPIs

• Alpha-glucosidase inhibitors

• lots of antibiotics

• misoprostol

What is the most frequent cause of diarrhea?

a. rotavirus

b. food intolerances

c. Campylobacter

d. E. coli

e. Norovirus

e. NOROVIRUS

What 2 viruses can cause bacteria. What is their tx?

Viruses: Rotavirus, Norovirus

tx: FLUID AND ELECTROLYTES (NOT ANTIBIOTICS!!!!!!!!)

What is a cause of diarrhea that can be prevented by giving a vaccine during childhood? What is the dosage form of the vaccine?

ROTAVIRUS- oral

Is diarrhea that is caused by viruses and bacteria self-limiting or not self-limiting?

self-limiting

Diarrhea that mainly affects the small intestine is _____________. Diarrhea that mainly affects the large intestine is ___________.

a. bloody, watery

b. watery, watery

c. bloody, bloody

d. watery, bloody

d

What are some causes of food intolerance diarrhea?

• food allergies

• spicy foods, fatty foods, lots of fibers

• lactase deficiency

What are some bacteria that cause diarrhea? What is the tx for ALL OF THEM? (excluding Traveler’s diarrhea here)

• Campylobacter

• Salmonella

• Shigella

• Staphylococcus aureus

• E.coli

TX: FLUIDS AND ELECTROLYTES!!!! NOT ANTIBIOTICS

How is each of the bacteria that cause diarrhea transmitted?

• Campylobacter

• Salmonella

• Shigella

• Staphylococcus aureus

• E.coli

• Campylobacter- cutting board/utensil contamination (ex: cut chicken on cutting board, then use same board and knife for veggies)

• Salmonella- uncooked/improperly frigerated poultry and dairy

• Shigella- contaminated water/veggies (includes swimming water!)

• Staphylococcus aureus- uncooked/improperly stored food

• E.coli- contaminated food, water, person-person, travel outside U.S.

What is the consistency of diarrhea caused by camphylobacter? (bloody, watery, chunky, etc.)

watery

What is the onset for diarrhea caused by campylobacter bacteria?

onset: 24-72 hours

What is the main bacteria that results in traveler’s diarrhea?

a. enterotoxigenic e. coli

b. shiga toxin-producing e. coli

c. enteroaggressive e.coli

a. enterotoxigenic e. coli

For shiga toxin-producing e.coli you should not use what tx?

anti-diarrheal (and abx ofc)

What are some causes of traveler’s diarrhea? (ex: fruit peels)

• fruit peels

• raw/undercooked meat

• contaminated WATER

• street vendor food

• hot sauce

• unpasteurized foods

• poorly stored food

What are some ways to prevent traveler’s diarrhea? (basically the opposite of the causes)

• drink out of bottled water

• avoid street vendors

• avoid hot sauces

• avoid BASICALLY ANYTHING THAT WOULD CAUSE- raw/uncooked meat, raw vegs, fruit peels

In general, is bismuth subsalicylate recommended to prevent traveler’s diarrhea?

no (NOT FOR PREVENTION, may use as tx)

What is the tx for mild and moderate/severe traveler’s diarrhea?

• mild- NO ANTIBIOTICS (can consider loperamide or bismuth)

• moderate/severe- antibiotics, loperamide

Why do the antibiotics used to tx moderate/severe traveler’s diarrhea vary depending on where you are?

different places of the world have different resistances to bacteria

• ex: Egypt may have a higher resistance to Rifaximin than Rifamycin, so if I’m in Egypt and get travel’s diarrhea I would chose Rifamycin, but this might be a whole different story if I was traveling in Thailand

When CAN’T loperamide be used for moderate/severe traveler’s diarrhea?

BLOODY DIARRHEA OR A FEVER DO NOT TAKE LOPERAMIDE!!!!!!!!!

WHAT IS THE SPECIFIC INDICATION for Rifaximin use in Traveler’s diarrhea?

treatment ≥ 12 YO w/ traveler’s diarrhea caused by NONINVASIVE STRAINS of E.coli (will no fever or bloody diarrhea)

WHAT IS THE SPECIFIC INDICATION for Rifamycin use in Traveler’s diarrhea?

treatment of adults with traveler’s diarrhea due to NONINVASIVE STRAINS of E.coli (will no fever or bloody diarrhea)

What are some counseling points for Rifamycin?

• DO NOT DRINK ALCOHOL

• swallow whole

• d/c if C.difficile occurs

What are some protozoa that can cause diarrhea?

• Giardia

• Cryptosporidia

Does Giardia cause short or long term diarrhea?

long (1-3 weeks)

What is the tx for each protozoal causing diarrhea?

• Giardia= fluids+ electrolytes+ azole (Metronidazole, tinidazole, or nitazoxanide)

• Cryptosporidia= fluid+electrolytes or Nitazoxanide (1 exception)

What is the 1 exception to using Nitazoxanide for tx of cryptosporidia?

CANNOT use in AIDS (or severely immunosuppressed)

With tinidazole and metronidazole, you MUST be careful about consuming ____________.

ALCOHOL

How long after taking metronidazole and tinidazole can you consume alcohol?

after 72 hours

PRACTICE:

With which of the following medications is alcohol not an issue?

a. Metronidazole

b. Rifamycin

c. Tinidazole

d. Rifaximin

d (ALL OTHERS DO NOT CONSUME ALCOHOL)

Match the following problems with the resulting stool color:

• Upper GI-_________

• Lower GI-_________

• Liver-________

Stool colors: yellow, black, red

• Upper GI-black

• Lower GI-red

• Liver-yellow

When should a patient be referred to their PCP for diarrhea? (ex: <_______ months old or diarrhea >_____hrs)

• < 6 months old

• pregnant

• sudden abdominal pain

• dehydration

• fever

• blood, mucus, pus

• diarrhea >48 hrs

What is classified as a persistent fever requiring a PCP visit?

• ≥102.2 in ≥3 months-old

• ≥100.4 in <3 months-old

Which of the following is recommended for rehydration in diarrhea?

a. sports drinks (Gatorade)

b. fruit juices

c. Pedialyte, Ceralyte

d. soda

c

Which of the following diets should you follow when having diarrhea? SATA

a. fatty foods

b. spicy foods and caffeine

c. vegetables, lean meats

d. yogurt, complex carbs

c,d

What are the C/I to loperamide use?

1. fever

2. bloody stools

3. fecal leukocytes

4. <6 YO

What is the max duration you can use loperamide and Lomotil?

48 hrs

What are the ADRs and BBW of loperamide?

ADRs- dizzy, constipation, abdominal pain

BBW- Torsade de Pointes

Why is loperamide in blister packs?

to prevent abuse

Lomotil is a schedule ___ drug.

IV