Therapeutics - GI
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What are the risk factors for GI infections?
- Recent travel to high risk area
- Depressed immune function
- Regional outbreak of food borne/waterborne illness
- Poor personal hygiene
- Disruption of normal barrier defense mechanisms
- Antibiotic exposure
What are the most common pathogens for infectious/bacterial diarrhea?
- Vibrio Cholerae
- E. coli – most common, subtypes:
- -enterotoxigenic (ETEC)*
- -enteroinvasive (EIEC)
- -enteroadhesive (EAEC)
- -enteropathogenic (EPEC)
- -enterohemorrhagic (EHEC) (O157:H7) – The deadly one
- Salmonella sp.
- Campylobacter sp.
- Staphylococcus aureus
- Clostridium difficile – Hospital acquired
Which bacterial diarrhea causative organism causes diarrhea after eating?
What are the complications of Diarrhea?
- Secretory or dysentery diarrhea
- Abdominal cramping and extension
- Electrolyte disturbances
- Mucous and bloody diarrhea
- Renal failure
- Hemolytic uremic syndrome
- renal failure
- hemolytic anemia
What needs to be replaced concurrently with fluids in a bacterial diarrhea patient?
Na and K
When does the CDC recommend taking prophylactics for traveler’s diarrhea?
What are the options for Traveler’s diarrhea prophylaxis?
- bismuth subsalicylate 2 tabs with meals and hs
- ciprofloxacin 500 mg BID
- Rifaximin 200mg 1-3 x daily
- Start 1 day before and end it 2 days after return
What is the recommended antibiotic for a patient with bacterial diarrhea caused by Non-Typhoid salmonella?
- (Same as Shigella)
What is the recommended antibiotic for a patient with bacterial diarrhea caused by Shigella?
- (same as Salmonella)
What is the recommended antibiotic for a patient with bacterial diarrhea caused by Campylobacter?
Erythromycin or other macrolide
What is the recommended antibiotic for a patient with bacterial diarrhea caused by Staph aureus?
What is the recommended antibiotics for a patient with bacterial diarrhea caused by E. coli?
What is the recommended antibiotics for a patient with bacterial diarrhea caused by Vibrio cholera?
Cipro or Azithromax
What is the WHO recommendation for replacement fluids (oral)?
- Glucose: 25 g/L
- Na: 75-90 mEq/L
- K: 20 mEq/L
What drugs are used for empiric treatment of VIRAL Diarrhea?
- Dipneoxylate/atropine (Lomotil)
- Quinolone (Cipro, oxifloxacin, etc.)
- Rifixamin(Xifaxin) 200 mg PO TID
- As long as not dysentery
Why is loperamide, Diphenoxylate, Quinolones and Rifixamin not recommended for dysentary patients?
- Duysentary is bacterial
- These drugs slow peristalsis and cause bacteria to be retained/not ejected, so bloating and worsening of disease occurs
What strain of C. diff Is often resistant to Flouroquinolones and cephalosporins?
Describe C. diff histology:
Gram + spore forming anerobe
What are the risk factors for C. diff infection?
- Promoted by an alteration in normal GI flora secondary to antibiotic exposure
- 55-75% of patients are post surgical with perioperative antibiotic exposure
- Other risk factors
- Recent bowel surgery
- Ischemic bowel
- Admitted from a skilled nursing facility
- PPI use
What are the normal choices for C. diff treatment?
- DOC: metronidazole 500 mg PO TID x 10-14 days
- Vancomycin oral 125-500 mg PO QID (Has to be oral)
What are the parameters for severe C. diff?
pseudomembranous colitis, marked leukocytosis (WBC > 15K), acute renal failure (>1.5 mg/dL), hypotension
What is the treatment for Severe C. diff?
Vancomycin 125 - 500 mg PO QID for 10-14 days and metronidazole 500 mg IV or PO QID-TID
What is the C. diff treatment for patients with severe disease and Toxic megacolon?
- Metronidazole 500 mg IV QID for 10-14 days
- Or Vancomycin retention enema - 500 mg-1 gm in 1-2 liters of isotonic saline every 4-12 hours
What percent of C. diff patients relapse?
How do you treat mild relapse in a C. diff patient?
Usually self resolving
How do you treat a Moderate to severe relapse in a C. diff patient?
Same approach as initial episode
How do you treat the Second Occurrence of C. diff relapse?
- Tapering dose of oral vancomycin
- 125 mg PO QID for 14 days
- 125 mg PO BID for 7 days
- 125 mg PO daily for 7 days
- 125 mg Q 48hr for 8 days
- 125 mg Q 72hr for 15 days
How do you treat the 3rd Occurrence of C. diff relapse?
Vancomycin 125 mg QID for 14 days followed by rifixamin 400 mg BID (not FDA-approved) for 14 days
What is the advantage of Fidaxomicin?
May reduce relapse, because it has post-antibiotic effect > 24 hours
What are the SE of Fidaxomicin?
Hypokalemia, elevated temp, headache, peripheral edema
What is the dose of Fidaxomicin?
200 mg PO BID
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