therapeutics bradley 2

Topic: Sexually Transmitted Diseases: infectious diseases transmitted through sexual activity

Can lead to long-term health consequences

• Infertility, facilitation of HIV transmission, stigmatization of subgroup populations

Significant economic burden

• STD treatment costs U.S. $16 billion annually
• Federally funded programs programs to reduce spread of gonorrhea, chlamydia, and syphilis

20 million new cases of STDs in the U.S. per year

• 50% among young people aged 15-24 years

Most common in U.S.: Gonorrhea, Chlamydia, Syphilis, HPV

STD Prevention

Universal precautions

• Practicing abstinence or maintaining a mutually monogamous sexual relationship with an uninfected partner
• Barrier contraceptive methods can decrease risk of transmission

• Latex condoms are more effective than natural skin condoms
• Oil based products for lubrication can weaken latex

HPV vaccination

HIV Pre-Exposure Prophylaxis or Post-Exposure Prophylaxis

Screening for STDs

Routine annual screening for Gonorrhea and Chlamydia in:

• Sexually active females < 25 years old
• At risk older women with previous infection, other STDs, new/several sex partners, inconsistent condom use, drug use
• Sexually active gay, bisexual, and other men who have sex with men (MSM)*
• At risk pregnant women

Routine annual screening for Syphilis in:

• Sexually active gay, bisexual, and other men who have sex with men (MSM)*
• All pregnant women

* MSM with multiple or anonymous partners should be screened for STDs at more frequent intervals (3-6 months)

STD 1: Gonorrhea - caused by Neisseria gonorrhoeae (gram-negative diplococci)

• Coinfection with gonorrhea and chlamydia occurs often, so when someone is diagnosed with gonorrhea, we assume that they have chlamydia as well, unless proven otherwise
• Infrequently infection can be asymptomatic - makes screening extremely important

Clinical Presentation

Symptom onset is 2-8 days for men and within 10 days for women

Symptoms are common, especially in males

• Males: Purulent urethral discharge or rectal discharge
• Females: Abnormal vaginal discharge or uterine bleeding
• Both: Dysuria and urinary frequency

Can cause infection of cervix, urethra, rectum and/or pharynx

Complications: pelvic inflammatory disease, ectopic pregnancy, infertility

Diagnosis: test for both gonorrhea and chlamydia via gram stain of urethral specimen

Other tests…

• Nucleic acid amplification test (NAAT) on endocervical, vaginal, urethral swabs or urine
• Culture requires endocervical (women) or urethral (men) swab specimen

What is the main issue that comes when treating gonorrhea?

The occurrence of antibiotic resistant gonorrhea is high

• High rates of fluoroquinolone resistance
• Increasing rates of cephalosporin resistance

***CDC recommends dual therapy for treatment of gonorrhea

Treatment of Uncomplicated Infection

Provides dual coverage of gonorrhea AND azithromycin provides coverage for chlamydia

• Should be administered together on the same day
• To maximize adherence and reduce complications/transmission, medication for gonococcal infection should be provided on side and de directly observed

Special Considerations

1. Severe penicillin/cephalosporin allergy (severe meaning anaphylaxis, Steven Johnson, toxic epidermal necrolysis)

1. Limited data on alternative regimens
2. Options include: Gentamicin 240mg IM x 1 dose + azithromycin 2g PO x 1 dose

2. Pregnancy

1. Ceftriaxone 250mg IM x 1 dose + azithromycin 1g PO x 1 dose
2. If penicillin allergy à consult ID specialist

Counseling Points/ Follow-Up

To minimize disease transmission patients should be instructed to:

• Abstain from sexual activity for 7 days after treatment and until all sex partners have been adequately treated
• Reinfection is possible

Any person diagnosed with gonorrhea should be screened for other STDs

• Test-of-cure is NOT needed for persons with uncomplicated urogenital or rectal gonorrhea who receive appropriate treatment
• Test-of-cure IS recommended for any person with pharyngeal gonorrhea

Expedited Partner Therapy (EPT) - recommended for chlamydia (more strict with EPT in gonorrhea due to high possibility of coinfections)

Clinical practice of treating the sex partners of persons who receive gonorrhea or chlamydia diagnoses without the healthcare provider examining the partner - Typically offered to all partners within preceding 60 days

• Medication/prescription provided to the patient to give to partner(s)
• Medication accompanied by treatment instructions, appropriate warnings, general health counseling, and a statement advising the partners seek medical evaluation

Not routinely recommended for MSM because of high risk of coexisting infection

Allowable in the majority of U.S. states

Regimen: Cefixime 400mg PO x 1 dose + azithromycin 1g PO x 1 dose

Benefits of EPT: partner can be treated quickly without having to go to the doctor first, patient will be protected from reinfection and neither patient or partner can pass the infection to others

STD 2: Chlamydia - caused by Chlamydia trachomatis (obligate intracellular organism)

• Chlamydia trachomatis: shares properties of both viruses and bacteria
• Women are 3x more likely to be infected than men
• Infection is commonly asymptomatic which makes annual screening extremely important

Clinical Presentation

Symptom onset 7-21 days for men and women

Can be symptomatic or asymptomatic (same symptoms as gonorrhea)

• Males: Purulent urethral discharge or rectal discharge
• Females: Abnormal vaginal discharge or uterine bleeding
• Both: Dysuria and urinary frequency

Complications: pelvic inflammatory disease, ectopic pregnancy, infertility

Diagnosis done through NAATs of urine specimen, endocervical, or vaginal swabs

• If someone is diagnosed with chlamydia, you don't have to treat for gonorrhea unless tested for gonorrhea.

Treatment

Treatment reduces risk of adverse reproductive health consequences

• Azithromycin preferred for patients with poor treatment adherence and unpredictable follow-up - only one time dose
• Azithromycin also covers mycoplasma genitalium - another cause of gonococcal urethritis

***To maximize adherence therapy with single dose azithromycin is typically preferred

Special Considerations

1. Pregnancy: Doxycycline is contraindicated in 2nd and 3rd trimesters

1. Recommended regimen: Azithromycin 1g PO as single dose
2. Alternative regimen: Amoxicillin 500mg PO TID x 7 days

Counseling Points/Follow-Up

To minimize disease transmission patients should be instructed to:

• Abstain from sexual activity for 7 days after single dose treatment, or until completion of 7-day regimen,  and until all sex partners have been adequately treated

Any person diagnosed with chlamydia should be screened for other STDs

Retesting for men and women recommended 3 months post treatment

• Higher risk of PID (pelvic inflammatory disease) and complications with repeat infection

Partners should be referred for evaluation or offered EPT

Case 1: TR is a 22 year old female presenting for her annual physical. She states that she feels well and has no complaints at this time. TR takes an oral contraceptive for birth control and reports missing doses 3-4x per week because she is forgetful. Her STD screen comes back positive for Chlamydia and her pregnancy test is negative.  She has NKDA. Which treatment regimen is most appropriate for TR?

A)TR does not need treatment because she is asymptomatic

B)TR should be treated with doxycycline 100mg PO q12h x 5 days

C)TR should be treated with azithromycin 1g PO as a single dose

D)TR should be treated with levofloxacin 500mg PO daily x 5 days

E)TR should be treated with erythromycin 500mg PO four times a day x 7 days

STD 3: Syphilis - caused by Treponema pallidum (gram-negative spirochete)

Disease divided into stages based on clinical findings (stages overlap but determine treatment)

• Most new cases in U.S are in MSM
• Acquired by sexual contact with infected mucus membrane or cutaneous lesion
• Contact with primary chance or ulcer spreads infection

Diagnosis

Presumptive diagnosis requires 2 tests:

1. Nontreponemal test: VDRL or RPR (if they come back positive, you do test 2)
2. Treponemal test: FTA-ABS, TP-PA, or immunoassay

Stages of Syphilis

Treatment

• Parenteral Penicillin G is the preferred drug for treating all stages of syphilis

• Preparation used, dose, and treatment duration depend on stage

Special Considerations

1. Penicillin allergy

1. Confirm allergy- consider desensitization (especially in pregnancy or neurologic involvement)**
2. Alternative:

1. Doxycycline 100mg PO q12h x 28 days
2. Tetracycline 500mg PO four times daily x 28 days
3. Ceftriaxone 1g IM or IV daily x 8-10 days (if allergy is mild)

2. Pregnancy: penicillin is drug of choice

***Desensitization to penicillin is very important because this is the only drug that works the best to cure syphilis

Jarisch-Herxheimer Reaction: allergic reaction that happens when the bacteria is killed upon treatment

• Acute reaction involving fever, headache, myalgia that can occur in the first 24 hrs after initiation of syphilis treatment
• Caused by release of toxic components of T.pallidum
• •Occurs most often in early syphilis due to higher bacterial burden
• Treatment is supportive care

Follow - Up

Follow-up syphilis tests are recommended 6 and 12 months after treatment for primary and secondary syphilis and again at 24 months for latent syphilis

• Response is a 4-fold reduction in antibody titer

HIV testing

Persons sexually exposed to primary, secondary, or early latent syphilis should be referred for clinical evaluation

• No EPT for syphilis

Case 2:

SS is a 39 year old man presenting with a diffuse rash, and generalized lymphadenopathy. He notes having a painless ulcer on his penis that resolved by itself about 5 weeks ago.  His RPR title was 1:64 and the FTA-ABS test was positive. SS is diagnosed with syphilis. He has NKDA.Which is the most appropriate treatment regimen for SS?

A) Benzathine penicillin G 2.4 million units IM once weekly for 3 weeks

B) Benzathine penicillin G 2.4 million units IM as single dose

C) Aqueous crystalline penicillin G 18-24 million units/day IV divided q4h x 10 days

D) Procaine penicillin 2.4 million units/day IM + probenecid 500mg PO QID x 10-14 days

E) Ceftriaxone 250mg IM as a single dose

STD 4: Herpes (no cure for condition)

Chronic, life long viral infection caused by Herpes Simplex Virus -1 (HSV-1) & Herpes Simplex Virus -2 (HSV-2)

• HSV-2 causes most cases of recurrent genital herpes

Many have mild or unrecognized infections but intermittently shed virus

Most genital herpes infections are transmitted by persons unaware they are infected

• Associated with a 2-4 fold increased risk of HIV acquisition if an individual is exposed when an outbreak is present
• Transmitted by the inoculation of infected secretions on mucosal surfaces

Herpes Cycle:

Primary infection → Infection of ganglia → Establish lifelong latency → Reactivation → Recurrent infection

Clinical Presentation

Incubation 2-14 days

1st episode of infection

• Several painful pustular, vesicular, or ulcerative lesions on external genitalia (usually develop over 7-10 days)

• Flu-like symptoms, local discharge, itching, burning, or pain
• Viral shedding lasts ~ 12 days

Recurrent infection (majority of patients)

• Prodrome symptoms before appearance of lesions
• Mild burning, itching, or tingling
• Fewer lesions than in primary and shorter duration
• Viral shedding lasts ~ 4 days

Recurrences and asymptomatic shedding more common with HSV-2

Treatment of Initial Episode of Herpes

Goal: to relieve symptoms and shorten clinical course

What are the types of treatments for recurrent syphilis?

1. Episodic therapy

• Patient provided with supply of drug and instructed to take immediately when HSV sx begin
• Goal: Ameliorate or shorten duration of lesions
• Option for persons with mild or infrequent recurrent outbreaks

2. Suppressive therapy

• Patient takes antiviral medication on a continuous basis
• Goal: Reduce frequency of recurrences
• Reduces risk of transmission to partners

Treatment for Episodic Syphilis

Should be initiated within 1 day of lesion onset or during the prodrome

• Many recommended regimens: generally higher doses and shorter durations

Treatment for Suppressive Therapy

Reduces frequency of genital herpes recurrences by 70-80%

• Providers should assess continued benefit of suppressive therapy periodically (once a year)

Counseling

Counseling of infected person and their sex partners is critical

• Discuss potential for sexual transmission of HSV during asymptomatic periods
• Avoid sexual activity with uninfected partner when lesions or prodromal symptoms present

Male latex condoms when used consistently and correctly can reduce (but not eliminate) the risk for genital herpes transmission

STD 5: Bacterial vaginosis, Trichomonas, Vulvovaginal candidiasis (vaginal infection)

Most women will have a vaginal infection during their lifetime

• Many symptomatic women seek OTC products before evaluation by medical provider

3 STDs characterized by vaginal discharge: bacterial vaginosis (BV), trichomoniasis, vulvovaginal candidiasis

Bacterial Vaginosis

Replacement of vaginal flora with anaerobic bacteria (G.vaginalis, Ureaplasma, Mycoplasma) causes BV

Risk factors:

• Multiple male/female partners
• A new sex partner
• Lack of condom use
• Lack of vaginal lactobacilli

BV associated bacteria can be found in male genitalia

• Treatment of male sex partner is not beneficial in preventing/reducing recurrence of BV

Increases risk of acquisition of other STDs including chlamydia and gonorrhea

Treatment of BV (recommended in women with symptoms)

Counseling

• Alcohol should be avoided during treatment with nitroimidazoles
• Clindamycin cream is oil-based, so it can weaken latex condoms
• Refrain from sexual activity or use condoms consistently and correctly during treatment

Trichomoniasis - caused by Trichomonas vaginalis

Majority of infected persons have minimal or no symptoms

• Infections might last for months to years
• Infection readily passed between sex partners even if asymptomatic
• Treatment of male partner is beneficial

Associated with 2-3x increased risk for HIV acquisition and adverse pregnancy outcomes

Disproportionately high rates of infection in black women, women ≥ 40 years old, STD clinic patients, incarcerated persons

Treatment of Trichomoniasis

***Tinidazole is more expensive but reaches higher levels in the GI tract, has a longer half life, & less GI adverse events

Goals of Treatment: reduce symptoms and signs of infection and might reduce transmission & reduce likelihood of adverse outcomes in women with HIV

Counseling

• Alcohol should be avoided during tx with nitroimidazoles

• Abstain from sex until patient and sex partner are treated

• Retesting recommended within 3 months of initial treatment

Vulvovaginal candidiasis (VVC) - mostly caused by Candida albicans

Can be classified as uncomplicated or complicated

1. Uncomplicated

• Sporadic or infrequent
• Mild to moderate
• Likely C.albicans
• Nonimmunocompromised

2. Complicated

• Recurrent, severe, non albicans, or immunocompromised

Treatment for Uncomplicated VVC (short course topical formulations)

Counseling

Symptom resolution takes ~3 days after initiation of treatment

• For women whose symptoms persist after using an OTC preparation or who has recurrence of symptoms within 2 months after treatment should see provider
• Creams and suppositories are oil-based and might weaken latex condoms/diaphragms

STD Key Points

1. Gonorrhea

• Requires dual antibiotic coverage because of increasing resistance
• Co-infection with Chlamydia is common – if diagnosed with Gonorrhea treat for chlamydia too!

2. Chlamydia

• Often asymptomatic- routine screening is important
• DOC is azithromycin due to ease of regimen

3. Syphilis

• Divided into stages based on length of infection and symptoms
• DOC is penicillin –stage of infection guides formulation and duration of tx

4. Genital Herpes

• Most cases of recurrence due to HSV-2
• Virus can be spread during periods of asymptomatic shedding
• Treatment regimens vary based on initial, recurrent or suppressive therapy

5. BV, Trich, VVC (common infections in women)

• BV: treatment of male sex partner is not beneficial
• Trich: treatment of male sex partner is beneficial
• VVC: uncomplicated infection can be self treated using OTCs, however misdiagnosis is common

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Topic: Gastrointestinal Infections

Clostridium Difficile Infection (CDI) - caused by Clostridium difficile AKA Clostridioides

• Spore-forming, toxin-producing, gram-positive, anaerobic bacillus

Has the potential to cause a wide spectrum of syndromes:

• Asymptomatic carriage, diarrhea of varying severity, colitis (with or without formation of pseudomembranes), toxic megacolon, perforation, death

Major identifiable cause of antibiotic associated diarrhea

Common in the community setting - high rates of recurrent infection

Transmissibility - highly transmissible via fecal-oral route by ingestion of spores

• Can be cultured from hospital rooms, hands, clothing and stethoscopes of health-care workers
• Special contact precautions required for patients with CDI to reduce transmission

• Alcohol-based hand sanitizers not as effective at removing C.diff spores
• Soap and water are the preferred hand hygiene technique

Stages of Infection

1. Disturbance of normal bacterial flora in colon
2. Colonization with C. difficile
3. Release of toxins that cause mucosal damage

Risk Factors

1. Modifiable:

• Antibiotic use (high versus low risk abx)
• Acid suppressing agents (PPIs have greater risk than H2RAs)

2. Non-modifiable:

• Advanced age ≥ 65
• End stage renal disease
• Immunosuppression
• Mechanical ventilation
• Recent hospital admission (within the past 60 days)

3. Community onset CDI:

• Potential for non-antibiotic risk factors
• Pregnancy

4. Environmental:

• Improper infection control

Types of Antibiotics Used in CDI

Diagnosis: patients with unexplained and new on-set ≥ 3 unformed liquid stools in 24 hours should be tested for CDI

• Patients receiving laxatives should not be tested!

Several test available, each with advantages and limitations

Guidelines recommend using stool toxin test as part of a multistep algorithm for diagnosis

C.diff diagnosed when lab test positive AND pt has unexplained and new onset ≥ 3 unformed stools in 24 hours

Repeat testing not recommended during the same episode of CDAD

Treatments

1. Discontinue therapy with inciting antibiotic(s) if possible*
2. Empiric therapy should be started while awaiting CDI diagnosis

Treatment regimen depends on initial vs recurrent infection and on disease severity

What is Fidaxomicin (Dificid)?

• MOA: inhibits RNA polymerase resulting in inhibition of protein synthesis and cell death of C.difficile
• Adverse reactions: nausea (11%), GI bleed (4%), abdominal pain, vomiting
• Warnings/Precautions: Use with caution in patients with a history of macrolide allergy!

What is Fecal Microbiota Transplant (FMT)?

Process which reintroduces normal intestinal flora into the GI tract of patients with CDI

• Healthy human donor stool is instilled into GI tract of diseased colon where normal flora is missing by means of oral route, nasogastric/gastric tube, per rectum

FDA regulatory status: not an approved drug but draft guidance policy on IND requirements for use of FMT

What is Bezlotuxumab (Zinplava)?

Indication: to reduce recurrence of CDI in patients ≥18 years and older who are receiving CDI treatment and are at high risk of recurrence

Not indicated for treatment of CDI - not discussed in 2017 IDSA CDI Guidelines

Dose: 10mg/kg IV as a single dose

MOA: IgG 1 monoclonal which binds C.diff toxinB and neutralizes it

Adverse reactions: Heart failure exacerbation (13%), headache (4%), gi (7%)

Warnings and precautions: Higher mortality rates observed in patients with history of heart failure treated with bezlotoxumab

Case 3:

JF is a 96 year old male recently discharged from the hospital after being treated pneumonia with cefepime. During his hospital admission he required mechanical ventilation and was subsequently started on omeprazole for stress ulcer prophylaxis. He is now presenting with suspected CDI.

What are JF’s non-modifiable risk factors for CDI?

A.High risk antibiotic use and use of acid suppressing agent

B.Age, antibiotic use, and recent hospitalization

C.Age, use of acid suppressing agent, and mechanical ventilation

D.Age, recent hospitalization, and mechanical ventilation

E.Age, antibiotic use, used of acid suppressing agent, recent hospitalization, and mechanical ventilation

JF continues to have multiple episodes of diarrhea per day. His stool is sent for testing and comes back positive for C.diff. His vital signs are stable and labs are notable for a WBC 17,000 cell/uL, and SCr 2.7. JF has a documented anaphylactic reaction to azithromycin.

What is the most appropriate treatment for JF?

A.Metronidazole 500mg PO q8h

B.Vancomycin 500mg PO q6h

C.Fidaxomicin 200mg PO q12h

D.Vancomycin 125mg PO q6h

E. FMT

Infectious Diarrhea  - caused by ingestion of food/water contaminated with pathogenic microorganisms (bacteria, viruses, parasites, fungi and protozoa)

Can be caused by…

• Bacterial: Salmonella, Shigella, Campylobacter, Traveler’s diarrhea
• Viral: Norovirus, Rotavirus
• Parasitic: Cryptosporidium, Giardia

One of the leading causes of death in developing countries (affects infants/kids living in poor sanitary/hygienic conditions)

Predisposing Factors

• Inadequate sanitation
• Ingestion of contaminated food or water
• Foreign travel
• Immunosuppression
• Day care centers
• Animal handlers
• Use of medications that increase gastric pH

Important Definitions

1. Diarrhea: 3 or more episodes of loose stools during a 24 hour period

2. Acute: Symptoms present for < 7 days

3. Prolonged: Symptoms last 7-13 days

4. Persistent: Symptoms present for 14-29 days

5. Chronic:  Symptoms present for > 30 days

What are the types of bacterial diarrhea?

1. Salmonella

• Acute onset of nausea, vomiting and bloody or non-bloody diarrhea
• Most infections acquired through poultry and livestock

2. Campylobacter

• Acute onset of bloody or non-bloody diarrhea
• Associated with undercooked poultry, can also be acquired from meat, dairy and contaminated water

3. Shigella

• Often presents with blood diarrhea
• Can produce Shiga Toxin which is extremely virulent
• Highly contagious- linked to outbreaks
• Day care centers are high risk

4. Escherichia coli O157:H7

• Enterohemorrhagic → causes severe bloody diarrhea
• Producer of Shiga Toxin
• Transmitted through contaminated meat

5. Escherichia coli non-O157:H7

• Associated with “traveler’s diarrhea”
• Spread through fecally contaminated food and water
• Most cases involve water diarrhea and resolve within 3 days without treatment

What are the types of viral diarrhea?

Presentation: watery, noninvasive diarrhea of acute onset, often associated with low-grade fever, headache and myalgia

• Symptoms are usually self-limited  and last < 48 hours
• May persist longer than a week in children, elderly, and hospitalized or immunocompromised patients

1. Norovirus

• Most common cause of acute diarrhea in adults

2. Rotavirus

• Most common cause of severe diarrhea in children < 2 years old

What are the types of parasitic diarrhea?

Less common in the developed world but most infections due to Cryptosporidium or Giardia lamblia

1. Cryptosporidium

• Self limited water diarrhea that presents within hours of ingestion of organism
• Can have prolonged and severe course in immunocompromised and elderly
• Transmitted fecal-orally
• Often acquired through contaminated swimming pools
• Can be acquired by travelers to developing countries

2. Giardia

• Delayed infection 7-14 days after ingestion of the cyst
• Presents as large-volume steatorrhea and is often associated with weight loss
• Usually self limited, but often lasts more than 7 days
• Transmitted fecal-orally
• Acquired via contaminated water and food or person to person contact in places with poor hygiene
• Less commonly can be sexually transmitted

Treatment for Infectious Diarrhea

1. Rehydration

• Oral rehydration: recommended to alleviate mild dehydration (might be asymptomatic)

• Should be done with oral rehydration salts mixed with water (ie Pedialyte)
• Advise consuming 1.5-2x the estimated volume of stool lost per day
• Sports drinks, fruit juices and chicken broth are inadequate for rehydration

• Intravenous rehydration: recommended for moderate to severe dehydration or mild dehydration with inability to take PO

• Should be done with crystalloids (ie Lactated ringers, Normal Saline)
• At least ½ the estimated volume deficit should be replaced in the first 4 hours after presentation
• Dextrose 5% in water is not adequate for rehydration

**Rehydration is needed for all diarrhea patients. Further treatment depends on etiology**

2. Ancillary treatment with antimotility, or antiemetic agents can be considered once patient is adequately hydrated

• NOT a substitute for fluid and electrolyte replacement

3. Antimotility agents (i.e loperamide)  

• Shouldn’t be given to children < 18 with acute diarrhea or patients with suspected or proven cases of toxic megacolon

4. Antiemetic agents (ie ondansetron)

• May be given to facilitate tolerance of oral rehydration or in acute gastroenteritis associated with vomiting

Treatment for Bacterial Diarrhea

Empiric antibiotic therapy - not recommended for immunocompetent

Recommended for:

• Infants < 3 months with suspicion of bacterial etiology
• Ill immunocompetent people with fever in a medical care facility or those presenting with sepsis
• Immunocompromised  with severe illness

Empiric therapy for adults: fluoroquinolone or azithromycin

Treatment for Parasitic Diarrhea

1. Cryptosporidium: Nitazoxanide

2. Giardia: Tinidazole or Nitazoxanide (Alt: Metronidazole)

Case 4:

LR is a 25 year old female who returned from a medical mission trip to Haiti 2 days ago. Since returning home she notes acute onset watery diarrhea ~ 3-4 x per day. She has no other systemic symptoms. LR comes to the pharmacy and asks for recommendations for rehydration. You recommend:

A.Gatorade, because it’s on sale and will adequately rehydrate her

B.Chicken soup, because it’s high in salt which is important for rehydration

C.Pedialyte, because it replaces both salts and electrolytes needed for rehydration

D.Water

E.Immediately going to the nearest emergency room for severe dehydration

GI Infections Key Points

1. C.diff: increasing incidence in the community

• Risk factors can be modifiable or nonmodifiable
• Requires special contact precautions and hand hygiene
• Treatment decisions based on severity of infection and initial vs recurrent episode
• 1st line treatment for initial episode is vancomycin or fidaxomicin

2. Infectious Diarrhea: caused by ingestion of contaminated food or water

• Bacterial causes: Salmonella, Shigella, Campylobacter and E.coli
• Viral causes: Norovirus, Rotavirus
• Parasitic causes: Cryptosporidium, Giardia
• Rehydration therapy is a mainstay of treatment regardless of etiology
• Usually self limiting, do not always require antimicrobial/parasitic treatment