GI infections

Debre Berhan University

Pharmacy Department
Integrated Therapeutic IV

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 Session Objectives
At the end of this session you will be able to;
• List common cause of GI infection
• Differentiate Dysenteric and watery Diarrhea
• Mention the Treatment approach of GI
pathogens
 Introduction
• Gastrointestinal (GI) infections are among the more
common causes of morbidity and mortality around
the world.
• Most are caused by viruses, and some are caused by
bacteria or other organisms.
• Viruses are now the leading global cause of
infectious diarrhea.
• Noroviruses, previously known as Norwalk-like
viruses, account for greater than 90% of viral
gastroenteritis among all age groups, and 50% of
outbreaks worldwide.

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• In underdeveloped and developing countries, acute
gastroenteritis involving diarrhea is the leading cause
of mortality in infants and children younger than 5
years of age.
– Because of dehydration
• Public health measures such as clean water supply
and sanitation facilities, as well as quality control of
commercial products, are important for the control
of most enteric infections.
• Sanitary food handling and preparation practices
significantly decrease the incidence of enteric
infections.

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Rehydration, Antimotility, And
Probiotic Therapy
• The cornerstone of management for all GI infections and
enterotoxigenic poisonings is to prevent dehydration by
correcting fluid and electrolyte imbalances.

• In mild, self limiting acute gastroenteritis, a diet of oral fluids

and easily digestible foods is recommended.

• In patients with severe dehydrating watery diarrhea and

dysenteric diarrhea, IV rehydration therapy, antibiotics, and/or
antimotility treatments are needed.
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 Rehydration, Antimotility, And
Probiotic Conti
 Initial assessment of fluid loss is essential for rehydration.

 Weight loss is the most reliable means of determining the

extent of water loss.

 Clinical signs such as changes in skin turgor, sunken eyes, dry

mucous membranes, decreased tearing, decreased urine output,
altered mentation, and changes in vital signs can be helpful in
determining approximate deficits.

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Treatment of diarrhea
– Fluid replacement is the cornerstone of therapy regardless
of etiology.
• Oral rehydration therapy (ORT)
– Components: glucose, sodium, potassium chloride, and
water
– Inexpensive, noninvasive, no need of hospitalization
– ORS should be given in small frequent volumes (5
mL every 2–3 minutes) in a teaspoon or oral
syringe.

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• IV fluid replacement:
 lactated Ringer’s solution or 0.9% sodium
chloride.
– Indications:
• Weight loss of 9% to 10%
• Uncontrolled vomiting,
• The presence of paralytic ileus,
• Early refeeding as tolerated is recommended.

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 Antimicrobial Therapy
• Antibiotics are not essential in the treatment of most
mild diarrhoeas.
• Empirical therapy for acute GI infections may result
in courses of unnecessary antibiotics.
• Antimotility Agents: offer symptomatic relief, but avoid if
there is high fever and bloody diarrhoeas.
• Antimotility drugs such as diphenoxylate and loperamide
offer symptomatic relief in patients with watery diarrhea by
reducing the number of stools.
• Antimotility drugs should be avoided if possible and are not
recommended in patients with many toxin-mediated
dysenteric diarrheas (ie, enterohemorrhagic Escherichia coli
[EHEC], pseudomembranous colitis, shigellosis).
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 BACTERIAL INFECTIONS
• They are important causes of GI infections.
• Divided into
– Those that cause watery (enterotoxigenic)
diarrhea or
– Those that cause dysentery (invasive diarrhea)

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 BACTERIAL INFECTIONS Cont…
• Common pathogens responsible for watery diarrhea are
norovirus, vibrocholerae, and enterotoxigenic Escherichia coli
(ETEC).
• Campylobacter spp., EHEC, Salmonella spp., and Shigella spp
are those most commonly associated with dysentery diarrhea.
• ETEC is also the most common cause of traveler’s diarrhea
and a common cause of food- and water-associated
outbreaks.
• Watery diarrhea is usually self-limiting.
• Whereas dysenteric ones require close monitoring and
intensive follow-up.

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 ENTEROTOXIGENIC (CHOLERA-LIKE) DIARRHEA
Cholera (Vibrio cholerae)

• V. cholerae is a gram-negative bacillus sharing similar

characteristics with the family Enterobacteriaceae

• V. cholerae O1 is the most common serogroup

associated with epidemics and pandemics

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• The hallmark of cholera is:
– The production of watery diarrhea, and severe
dehydration may develop within a few hours,
causing death within 24 hours.

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• The incubation period of V. cholerae is 1 to 3 days.
• Patients may lose up to 1 L of isotonic fluid every
hour.
• Fever occurs in less than 5% of patients.
• In the most severe state, this disease can progress to
death in a matter of 2 to 4 hours if not treated.

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Treatment
– ORT to restore fluid and electrolyte losses.
– In patients who cannot tolerate ORT, IV therapy with
Ringer’s lactate can be used
• Antibiotics
– Shorten the duration of diarrhea,
– Decrease the volume of fluid lost, and
– Shorten the duration of the carrier state

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Which antibiotics?
For children
― Erythromycin 30 mg/kg/ day divided every 8
hours orally × 3 days
― azithromycin 10 mg/kg/ day given orally once daily
× 3 days
 For Adults
― Doxycycline 300 mg orally × 1 day
Alternatives: azithromycin 500 mg orally once daily × 3
days; ciprofloxacin 750 mg orally once daily × 3 days;
ceftriaxone IV 20
 TTRAVELER’S DIARRHEAELER’S
DIARRHEA
• Traveler’s diarrhea describes the clinical syndrome caused by
contaminated food or water that is manifested by malaise,
anorexia, and abdominal cramps followed by the sudden onset of
diarrhea that incapacitates many travelers.

• The most common pathogens are bacterial in nature and include,

Shigella, Campylobacter, and Salmonella.

• Viruses are also potential causes.

• Patient education in avoiding high-risk food and beverages should

be the best method for minimizing the risk.

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 TTRAVELER’S DIARRHEA
Conti…ELER’S
Treatment for Adults
• Ciprofloxacin 750 mg orally × 1 day or 500
mg orally every 12 hours × 3 days;
• Levofloxacin 1000 mg orally × 1 day or 500
mg orally daily × 3 days;
• Rifaximin 200 mg three times daily × 3 days;
• Azithromycin 1000 mg orally × 1 day or 500
mg orally daily × 3 days
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 PSEUDOMEMBRANOUS COLITIS
(CLOSTRIDIUM DIFFICILE)
• Results from toxins produced by Clostridium
difficile.
• C. difficile is the most commonly recognized cause of
infectious diarrhea in healthcare settings with high rates of
disease in the elderly and those exposed to antibiotic agents.
• The antibiotics most commonly associated with C. difficile
infection (CDI) include,
– clindamycin, carbapenems, and third-/fourth-generation
cephalosporins, fluoroquinolones.
– Other risk factors for acquisition of C. difficile include
recent healthcare exposure, chemotherapy, patients
undergoing GI surgery or receiving tube feeding, and
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potentially those receiving acid suppressive medications.
• Rx
– Metronidazole, vancomycin, and fidaxomicin are
the most commonly prescribed agents.
– Initial therapy should also include discontinuation
of the offending agent.
– The patient should be supported with fluid and
electrolyte replacement.

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INVASIVE (DYSENTERY-LIKE) DIARRHEA

• BACILLARY DYSENTERY (SHIGELLOSIS)

– The shigellae are gram-negative bacilli belonging to the
family Enterobacteriaceae

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• Risk factors :
– Poor sanitation,
– Inadequate water supply,
– Malnutrition , and increased population density
• Presentation:
– Abdominal pain,
– Cramping and fever
– Severe abdominal pain, and tenderness prior to the
development of bloody diarrhea.

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• Treatment
– Generally includes correction of fluid and electrolyte
disturbances and, occasionally, antimicrobials
⁎ Treatment of Shigellosis for children
–Azithromycin 10 mg/kg/day given orally once daily × 3 days;
– ceftriaxone 50 mg/ kg/day given IV once daily × 3 days

⁎ Treatment of Shigellosis for Adult

— Azithromycin 500 mg orally once daily × 3 days;
— ceftriaxone 2 g IV/IM once; ciprofloxacin 750 mg orally once
daily × 3 days
• Alternatives: ampicillin 250–500 mg orally every 6 hours × 7
days;
• trimethoprim– sulfamethoxazole 160/800 mg twice daily × 7
days
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 SALMONELLOSIS
• Salmonella species are gram-negative bacilli
belonging to the family Enterobacteriaceae.
• Human disease caused by Salmonella generally falls
into four categories:
– Acute gastroenteritis (enterocolitis),
– Bacteremia ,
– Extraintestinal localized infection, and
– Enteric fever (typhoid and paratyphoid fever), and a
chronic carrier state.

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• Clinical prestn:
 For enterocolitis:
– Complain of nausea and vomiting within 72 hours of
ingestion.
– Followed by crampy abdominal pain, fever, and diarrhea.

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• Enteric Fever (Typhoid and Paratyphoid)

– The clinical presentations of typhoid fever and

paratyphoid fever generally are indistinguishable,
although paratyphoid fever tends to be less severe
than typhoid fever.
– The incubation period can range from 10 to 14
days.
– The onset of symptoms is gradual.
– Nonspecific symptoms of fever, dull headache,
malaise, anorexia, and myalgia are most common
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• Fever tends to be remittent, but it progresses
gradually over the first week to temperatures that
are often sustained higher than 40°C (104°F).

• Other frequently encountered symptoms include

chills, nausea, vomiting, cough, weakness, and sore
throat.

• Symptoms subside slowly within 4 weeks.

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 Treatment of salmonellossis
• Most patients with enterocolitis require no
therapeutic intervention

• fluid and electrolyte replacement

• Antibiotics choice
– Fluoroquinolones , trimethoprim-sulfamethoxazole,
ampicillin, and third-generation cephalosporins.
– Azithromycin and aztreonam also have been studied and
may be used as alternative agents

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• For bacteremia, if life-threatening, treatment should
include the combination of a third-generation
cephalosporin (ceftriaxone 2 g IV daily) and
ciprofloxacin 500 mg orally twice daily.

• For the treatment of enteric fever: Fluoroquinolones

are the drugs of choice.

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• A short course of 3 to 5 days is effective but a
minimum of 10 days is recommended in severe
cases.

• The third-generation cephalosporins (e.g.,

ceftriaxone, cefixime, cefotaxime, and cefoperazone)
and azithromycin are also effective drugs for typhoid.

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• The drug of choice for chronic carriers of Salmonella
is norfloxacin, 400mg orally twice daily for 28 days.

• amoxicillin and trimethoprim-sulfamethoxazole are

effective in eradicating the bacteria in greater than
80% of cases after 6 weeks of therapy

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Thank you!!!

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